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Chan KW, Kwong ASK, Tsui PN, Chan GCW, Choi WF, Yiu WH, Cheung SCY, Wong MMY, Zhang ZJ, Tan KCB, Lao L, Lai KN, Tang SCW. Add-on astragalus in type 2 diabetes and chronic kidney disease: A multi-center, assessor-blind, randomized controlled trial. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2024; 130:155457. [PMID: 38810556 DOI: 10.1016/j.phymed.2024.155457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 02/03/2024] [Accepted: 02/14/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND Diabetes leads to chronic kidney disease (CKD) and kidney failure, requiring dialysis or transplantation. Astragalus, a common herbal medicine and US pharmacopeia-registered food ingredient, is shown kidney protective by retrospective and preclinical data but with limited long-term prospective clinical evidence. This trial aimed to assess the effectiveness of astragalus on kidney function decline in macroalbuminuric diabetic CKD patients. METHODS This randomized, assessor-blind, standard care-controlled, multi-center clinical trial randomly assigned 118 patients with estimated glomerular filtration rate (eGFR) of 30-90 ml/min/1.73m2 and urinary albumin-to-creatinine ratio (UACR) of 300-5000 mg/g from 7 public outpatient clinics and the community in Hong Kong between July 2018 and April 2022 to add-on oral astragalus granules (15 gs of raw herbs daily equivalent) or to continue standard care alone as control for 48 weeks. Primary outcomes were the slope of change of eGFR (used for sample size calculation) and UACR of the intention-to-treat population. Secondary outcomes included endpoint blood pressures, biochemistry, biomarkers, concomitant drug change and adverse events. (ClinicalTrials.gov: NCT03535935) RESULTS: During the 48-week period, the estimated difference in the slope of eGFR decline was 4.6 ml/min/1.73m2 per year (95 %CI: 1.5 to 7.6, p = 0.003) slower with astragalus. For UACR, the estimated inter-group proportional difference in the slope of change was insignificant (1.14, 95 %CI: 0.85 to 1.52, p = 0.392). 117 adverse events from 31 astragalus-treated patients and 41 standard care-controlled patients were documented. The 48-week endpoint systolic blood pressure was 7.9 mmHg lower (95 %CI: -12.9 to -2.8, p = 0.003) in the astragalus-treated patients. 113 (96 %) and 107 (91 %) patients had post-randomization and endpoint primary outcome measures, respectively. CONCLUSION In patients with type 2 diabetes, stage 2 to 3 CKD and macroalbuminuria, add-on astragalus for 48 weeks further stabilized kidney function on top of standard care.
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Affiliation(s)
- Kam Wa Chan
- Division of Nephrology, Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Alfred Siu Kei Kwong
- Department of Family Medicine and Primary Healthcare, Hospital Authority Hong Kong West Cluster, Hong Kong Special Administrative Region, China
| | - Pun Nang Tsui
- Department of Family Medicine and Primary Healthcare, Hospital Authority Hong Kong East Cluster, Hong Kong Special Administrative Region, China
| | - Gary Chi Wang Chan
- Division of Nephrology, Department of Medicine, Queen Mary Hospital, Hong Kong Special Administrative Region, China
| | - Wing Fai Choi
- School of Chinese Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Wai Han Yiu
- Division of Nephrology, Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Simon Chi Yuen Cheung
- Division of Nephrology, Department of Medicine, Queen Elizabeth Hospital, Hong Kong Special Administrative Region, China
| | - Michelle Man Ying Wong
- Department of Family Medicine and Primary Healthcare, Hospital Authority Hong Kong East Cluster, Hong Kong Special Administrative Region, China
| | - Zhang-Jin Zhang
- School of Chinese Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Kathryn Choon Beng Tan
- Division of Endocrinology, Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Lixing Lao
- School of Chinese Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China; Virginia University of Integrative Medicine, VA, USA
| | - Kar Neng Lai
- Division of Nephrology, Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Sydney Chi Wai Tang
- Division of Nephrology, Department of Medicine, School of Clinical Medicine, The University of Hong Kong, Hong Kong Special Administrative Region, China.
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Heerspink HJL, Eddington D, Chaudhari J, Estacio R, Imai E, Goicoechea M, Hannedouche T, Haynes R, Jafar TH, Johnson DW, van Kruijsdijk RCM, Lewis JB, Li PKT, Neuen BL, Perrone RD, Ruggenenti P, Wanner C, Woodward M, Xie D, Greene T, Inker LA. A meta-analysis of randomized controlled clinical trials implications of acute treatment effects on glomerular filtration rate for long-term kidney protection. Kidney Int 2024:S0085-2538(24)00405-8. [PMID: 38901604 DOI: 10.1016/j.kint.2024.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 05/07/2024] [Accepted: 05/29/2024] [Indexed: 06/22/2024]
Abstract
Pharmacologic interventions to slow chronic kidney disease progression, such as ACE-inhibitors, angiotensin receptor blockers, or sodium glucose co-transporter 2 inhibitors, often produce acute treatment effects on glomerular filtration rate (GFR) that differ from their long-term chronic treatment effects. Observational studies assessing the implications of acute effects cannot distinguish acute effects from GFR changes unrelated to the treatment. Here, we performed meta-regression analysis of multiple trials to isolate acute effects to determine their long-term implications. In 64 randomized controlled trials (RCTs), enrolling 154,045 participants, we estimated acute effects as the mean between-group difference in GFR slope from baseline to three months, effects on chronic GFR slope (starting at three months after randomization), and effects on three composite kidney endpoints defined by kidney failure (GFR 15 ml/min/1.73m2 or less, chronic dialysis, or kidney transplantation) or sustained GFR declines of 30%, 40% or 57% decline, respectively. We used Bayesian meta-regression to relate acute effects with treatment effects on chronic slope and the composite kidney endpoints. Overall, acute effects were not associated with treatment effects on chronic slope. Acute effects were associated with the treatment effects on composite kidney outcomes such that larger negative acute effects were associated with lesser beneficial effects on the composite kidney endpoints. Associations were stronger when the kidney composite endpoints were defined by smaller thresholds of GFR decline (30% or 40%). Results were similar in a subgroup of interventions with supposedly hemodynamic effects that acutely reduce GFR. For studies with GFR 60 mL/min/1.73m2 or under, negative acute effects were associated with larger beneficial effects on chronic GFR slope. Thus, our data from a large and diverse set of RCTs suggests that acute effects of interventions may influence the treatment effect on clinical kidney outcomes.
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Affiliation(s)
- Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Devin Eddington
- Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Juhi Chaudhari
- Division of Nephrology, Tufts Medical Center, Boston, MA, USA
| | | | - Enyu Imai
- Nakayamadera Imai Clinic, Takarazuka, Japan
| | - Marian Goicoechea
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Thierry Hannedouche
- Service de Néphrologie, Hôpitaux Universitaires de Strasbourg, Faculté de Médecine, Strasbourg, France
| | - Richard Haynes
- Medical Research Council Population Health Research Unit, University of Oxford, Oxford, UK
| | - Tazeen H Jafar
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - David W Johnson
- Australasian Kidney Trials Network, University of Queensland, Brisbane, Australia
| | | | - Julia B Lewis
- Division of Nephrology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Philip K T Li
- Division of Nephrology, Prince of Wales Hospital, Chinese University of Hong Kong, Shatin, Hong Kong
| | - Brendon L Neuen
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | | | - Piero Ruggenenti
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, and Unit of Nephrology, Azienda Ospedaliera Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Christoph Wanner
- Department of Clinical Research and Epidemiology, Renal Research Unit, Comprehensive Heart Failure Center, University of Würzburg, Würzburg, Germany
| | - Mark Woodward
- The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia; The George Institute for Global Health, School of Public Health, Imperial College London, London, UK
| | - Di Xie
- Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Tom Greene
- Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Lesley A Inker
- Division of Nephrology, Tufts Medical Center, Boston, MA, USA.
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3
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Akihisa T, Kataoka H, Makabe S, Manabe S, Yoshida R, Ushio Y, Sato M, Yajima A, Hanafusa N, Tsuchiya K, Nitta K, Hoshino J, Mochizuki T. Immediate drop of urine osmolality upon tolvaptan initiation predicts impact on renal prognosis in patients with ADPKD. Nephrol Dial Transplant 2024; 39:1008-1015. [PMID: 37935473 DOI: 10.1093/ndt/gfad232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Indexed: 11/09/2023] Open
Abstract
BACKGROUND Tolvaptan, a vasopressin V2 receptor antagonist, is used for treating autosomal dominant polycystic kidney disease (ADPKD). We focused on changes in urinary osmolality (U-Osm) after tolvaptan initiation to determine whether they were associated with the therapeutic response to tolvaptan. METHODS This was a single-centre, prospective, observational cohort study. Seventy-two patients with ADPKD who received tolvaptan were recruited. We analysed the relationship between changes in U-Osm and annual estimated glomerular filtration rate (eGFR) in terms of renal prognostic value using univariable and multivariable linear regression analyses. RESULTS The mean value of U-Osm immediately before tolvaptan initiation was 351.8 ± 142.2 mOsm/kg H2O, which decreased to 97.6 ± 23.8 mOsm/kg H2O in the evening. The decrease in U-Osm was maintained in the outpatient clinic 1 month later. However, the 1-month values of U-Osm showed higher variability (160.2 ± 83.8 mOsm/kg H2O) than did those in the first evening of tolvaptan administration. Multivariate analysis revealed that the baseline eGFR, baseline urinary protein and U-Osm change in the evening of the day of admission (initial U-Osm drop) were significantly correlated with the subsequent annual change in eGFR. CONCLUSIONS U-Osm can be measured easily and rapidly, and U-Osm change within a short time after tolvaptan initiation may be a useful index for the renal prognosis in actual clinical practice.
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Affiliation(s)
- Taro Akihisa
- Department of Nephrology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, Japan
| | - Hiroshi Kataoka
- Department of Nephrology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, Japan
| | - Shiho Makabe
- Department of Nephrology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, Japan
| | - Shun Manabe
- Department of Nephrology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, Japan
| | - Rie Yoshida
- Department of Nephrology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, Japan
| | - Yusuke Ushio
- Department of Nephrology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, Japan
| | - Masayo Sato
- Department of Nephrology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, Japan
| | - Aiji Yajima
- Department of Blood Purification, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, Japan
| | - Norio Hanafusa
- Department of Blood Purification, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, Japan
| | - Ken Tsuchiya
- Department of Blood Purification, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, Japan
| | - Kosaku Nitta
- Department of Nephrology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, Japan
| | - Junichi Hoshino
- Department of Nephrology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, Japan
| | - Toshio Mochizuki
- Department of Nephrology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, Japan
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Hamid A, Greene SJ, Mehta A, Butler J, Khan MS. Estimated Glomerular Filtration Rate Slope as an Endpoint in Cardiovascular Trials. Curr Heart Fail Rep 2024:10.1007/s11897-024-00668-8. [PMID: 38795231 DOI: 10.1007/s11897-024-00668-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/08/2024] [Indexed: 05/27/2024]
Abstract
PURPOSE OF REVIEW End stage kidney disease can be a slow process and it may be challenging to achieve required follow-up for sufficient events. Therefore, a surrogate kidney endpoint, such as estimated glomerular filtration rate (eGFR) slope maybe attractive to assess the kidney in cardiovascular trials, especially heart failure (HF). RECENT FINDINGS eGFR slope can generate informative results in a shorter follow-up period, has decreased risk of type-2 error, and is less sensitive to eGFR shifts compared with other surrogate kidney endpoints (eGFR decline≥40% or doubling creatinine). However, eGFR slope has its limitations with acute effects, heterogeneity in slope calculation/reporting, and deviations from linearity. eGFR slope is a kidney endpoint which may be well-suited for HF trials. Cross-collaborated guideline recommendations are needed to optimize the use of eGFR slope as a kidney endpoint in patients with HF.
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Affiliation(s)
- Arsalan Hamid
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Stephen J Greene
- Duke Clinical Research Institute, Durham, NC, USA
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | - Ankit Mehta
- Division of Nephrology, Department of Internal Medicine, Baylor University Medical Center, Dallas, TX, USA
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
- Baylor Scott and White Research Institute, Dallas, TX, USA
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5
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Cao C, Wei S, He L, Li C, Lu Y, Sun W, Wang Y. Temporal alteration of serum bilirubin levels and its renoprotective effects in diabetic kidney disease: exploring the hormonal mechanisms. Front Endocrinol (Lausanne) 2024; 15:1361840. [PMID: 38756998 PMCID: PMC11097656 DOI: 10.3389/fendo.2024.1361840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 04/18/2024] [Indexed: 05/18/2024] Open
Abstract
Objective This current study represents a novel endeavor to scrutinize the correlation between the temporal alteration in serum total bilirubin (TBIL) concentrations and the rate of estimated glomerular filtration rate (eGFR). Additionally, this study aims to probe the plausible molecular mechanism underpinning the renoprotective effects of bilirubin concerning its hormonal characteristics. Materials and methods In this study, a cohort of 103 patients diagnosed with DKD and receiving medical care at Dongzhimen Hospital were recruited and monitored over a period of 2-7 years. The progression of DKD was ascertained using a threshold of eGFR decline > -5.48%/year. To assess the relationship between the annual change in serum TBIL levels (%/year) and the slope of eGFR, multivariate binary logistic regression analysis was employed. Furthermore, the ROC curve analysis was employed to determine the cut-off value for TBIL levels (%/year). Results The use of multivariate binary logistic regression models revealed that serum TBIL levels (%/year) exhibited a significant correlation with the slope of eGFR. Moreover, the ROC curve analysis indicated a cut-off value of -6.729%/year for TBIL levels (%/year) with a sensitivity of 0.75 and specificity of 0.603, in diagnosing eGFR decline >-5.48%/year. Conclusions The findings of this study suggest that the sustained elevation of serum bilirubin concentration within the physiological range can effectively retard the progression of Diabetic Kidney Disease (DKD). Furthermore, the hormonal attributes of bilirubin may underlie its renoprotective effects.
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Affiliation(s)
- Can Cao
- Department of Nephrology and Endocrinology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Shuwu Wei
- Department of Nephrology and Endocrinology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Leijuan He
- Department of Traditional Chinese Medicine, Dadushe Community Health Service Center, Beijing, China
| | - Chunyao Li
- Department of Nephrology and Endocrinology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Yizhen Lu
- Department of Nephrology and Endocrinology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Weiwei Sun
- Department of Nephrology and Endocrinology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Yaoxian Wang
- Department of Nephrology and Endocrinology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
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6
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Nakhleh A, Abdul-Ghani M, Gazit S, Gross A, Livnat I, Greenbloom M, Yarden A, Khazim K, Shehadeh N, Melzer Cohen C. Real-world effectiveness of sodium-glucose cotransporter-2 inhibitors on the progression of chronic kidney disease in patients without diabetes, with and without albuminuria. Diabetes Obes Metab 2024. [PMID: 38680053 DOI: 10.1111/dom.15623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 04/05/2024] [Accepted: 04/12/2024] [Indexed: 05/01/2024]
Abstract
AIM To examine the renal effects of sodium-glucose cotransporter-2 (SGLT2) inhibition among non-diabetic individuals with chronic kidney disease (CKD) in a real-world setting. METHODS We collected de-identified data on adults without diabetes and with an estimated glomerular filtration rate (eGFR) of 25-60 mL/min/1.73 m2, who initiated the SGLT2 inhibitors dapagliflozin or empagliflozin between September 2020 and November 2022 at Maccabi Healthcare Services, an Israeli health maintenance organization. We assessed the effects of SGLT2 inhibitors on renal function (changes in eGFR slope/time). Index date was defined as the date of the first dispensing of SGLT2 inhibitors. Annual baseline slope was calculated using all eGFR measurements during the 2 years prior to index date (median = 7 measurements), while annual follow-up slope was calculated from all evaluations during 90-900 days post index date, along with baseline measurement at index date (median = 6 measurements). Paired t tests were used to compare differences between baseline and follow-up annual slopes. RESULTS Of a total of 354 participants with CKD, without diabetes, who received SGLT2 inhibitors and were followed for a median of 527 days, the mean age was 72.8 ± 11.8 years, 26% were female, and 91% used renin-angiotensin system blockade. The mean eGFR was 45.4 ± 9.5 mL/min/1.73 m2. The mean body mass index was 29.1 ± 5.4 kg/m2. During the year before index date, 146 participants (41%) had a urinary albumin to creatinine ratio (UACR) <30 mg/g, 81 (23%) had a UACR of 30-300 mg/g, 74 (21%) had a UACR >300 mg/g, and 53 (15%) had no UACR evaluation. The mean eGFR slope over time was -5.6 ± 7.7 mL/min/1.73 m2 per year at baseline, which improved to -1.7 ± 6.8 mL/min/1.73 m2 per year after SGLT2 inhibitor administration (p <0.001). This effect was independent of UACR. CONCLUSION In a real-world study of primarily older non-diabetic adults with CKD, SGLT2 inhibition was associated with a slower rate of kidney function decline, regardless of baseline UACR level.
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Affiliation(s)
- Afif Nakhleh
- Diabetes and Endocrinology Clinic, Maccabi Healthcare Services, Haifa, Israel
- Institute of Endocrinology, Diabetes and Metabolism, Rambam Health Care Campus, Haifa, Israel
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
| | - Muhammad Abdul-Ghani
- Diabetes and Endocrinology Clinic, Maccabi Healthcare Services, Haifa, Israel
- Division of Diabetes, University of Texas Health Science Centre, San Antonio, Texas, USA
| | - Sivan Gazit
- Maccabi Institute for Research and Innovation, Tel-Aviv, Israel
| | - Adi Gross
- Medical Affairs, AstraZeneca, Kfar Saba, Israel
| | - Idit Livnat
- Medical Affairs, AstraZeneca, Kfar Saba, Israel
| | | | - Adva Yarden
- Medical Affairs, AstraZeneca, Kfar Saba, Israel
| | - Khaled Khazim
- Diabetes and Endocrinology Clinic, Maccabi Healthcare Services, Haifa, Israel
| | - Naim Shehadeh
- Diabetes and Endocrinology Clinic, Maccabi Healthcare Services, Haifa, Israel
- Institute of Endocrinology, Diabetes and Metabolism, Rambam Health Care Campus, Haifa, Israel
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed, Israel
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7
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Su B, Jiang Y, Li Z, Zhou J, Rong L, Feng S, Zhong F, Sun S, Zhang D, Xia Z, Feng C, Huang W, Li X, Chen C, Hao Z, Wang M, Qin L, Chen M, Li Y, Ding J, Bao Y, Liu X, Deng F, Cheng X, Zhang L, Zhang X, Yang H, Peng X, Sun Q, Deng L, Jiang X, Xie M, Gao Y, Yu L, Liu L, Gao C, Mao J, Zheng W, Dang X, Xia H, Wang Y, Zhong X, Ding J, Lv J, Zhang H. Are children with IgA nephropathy different from adult patients? Pediatr Nephrol 2024:10.1007/s00467-024-06361-1. [PMID: 38578470 DOI: 10.1007/s00467-024-06361-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 03/14/2024] [Accepted: 03/24/2024] [Indexed: 04/06/2024]
Abstract
BACKGROUND Previously, several studies have indicated that pediatric IgA nephropathy (IgAN) might be different from adult IgAN, and treatment strategies might be also different between pediatric IgAN and adult IgAN. METHODS We analyzed two prospective cohorts established by pediatric and adult nephrologists, respectively. A comprehensive analysis was performed investigating the difference in clinical and pathological characteristics, treatment, and prognosis between children and adults with IgAN. RESULTS A total of 1015 children and 1911 adults with IgAN were eligible for analysis. More frequent gross hematuria (88% vs. 20%, p < 0.0001) and higher proteinuria (1.8 vs. 1.3 g/d, p < 0.0001) were seen in children compared to adults. In comparison, the estimated glomerular filtration rate (eGFR) was lower in adults (80.4 vs. 163 ml/min/1.73 m2, p < 0.0001). Hypertension was more prevalent in adult patients. Pathologically, a higher proportion of M1 was revealed (62% vs. 39%, p < 0.0001) in children than in adults. S1 (62% vs. 28%, p < 0.0001) and T1-2 (34% vs. 8%, p < 0.0001) were more frequent in adults. Adjusted by proteinuria, eGFR, and hypertension, children were more likely to be treated with glucocorticoids than adults (87% vs. 45%, p < 0.0001). After propensity score matching, in IgAN with proteinuria > 1 g/d, children treated with steroids were 1.87 (95% CI 1.16-3.02, p = 0.01) times more likely to reach complete remission of proteinuria compared with adults treated with steroids. CONCLUSIONS Children present significantly differently from adults with IgAN in clinical and pathological manifestations and disease progression. Steroid response might be better in children.
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Affiliation(s)
- Baige Su
- Department of Pediatric Nephrology, Peking University First Hospital, No. 1 Xi An Men Da Jie, Beijing, 100034, People's Republic of China
| | - Yuanyuan Jiang
- Renal Division, Peking University First Hospital, No.8 Xi Shi Ku Da Jie, Beijing, 100034, People's Republic of China
- Department of Nephrology, Beijing Hospital of Traditional Chinese Medicine, Capital Medical University, Beijing, China
| | - Zhihui Li
- Department of Nephrology, Rheumatology and Immunology, Hunan Children's Hospital, Changsha, Hunan, China
| | - Jianhua Zhou
- Department of Pediatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430030, Hubei Province, China
| | - Liping Rong
- Department of Pediatric Nephrology and Rheumatology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Shipin Feng
- Department of Pediatric Nephrology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Fazhan Zhong
- Pediatric Nephrology Department, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510623, Guangdong, China
| | - Shuzhen Sun
- Department of Pediatric Nephrology and Rheumatism and Immunology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250021, China
| | - Dongfeng Zhang
- Nephrology and Immunology Department, Children's Hospital of Hebei Province, Shijiazhuang, Hebei Province, China
| | - Zhengkun Xia
- Department of Pediatrics, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Chunyue Feng
- Department of Nephrology, Children Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Wenyan Huang
- Department of Nephrology and Rheumatology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xiaoyan Li
- Department of Pediatrics, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Chaoying Chen
- Department of Nephrology, Children's Hospital Affiliated to Capital Institute of Pediatrics, Beijing, China
| | - Zhihong Hao
- Department of Pediatric, Guangzhou First People's Hospital, the Second Affiliated Hospital of South China University of Technology, Guangzhou, China
| | - Mo Wang
- Department of Nephrology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Li Qin
- Department of Pediatrics, The First People's Hospital of Yunnan Province, The Affiliated Hospital of Kunming Science and Technology University, Kunming, China
| | - Minguang Chen
- Department of Pediatric Nephrology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yuanyuan Li
- Department of Pediatrics, Fuzong Clinical Medical College, Fujian Medical University, Fuzhou, 350025, China
- Department of Nephrology, Rheumatology and Immunology, Fujian Children's Hospital, Fuzhou, 350014, China
| | - Juanjuan Ding
- Department of Pediatric Nephrology, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430016, Hubei, China
| | - Ying Bao
- Department of Nephrology, Xi'an Children's Hospital, Xian, Shaanxi, China
| | - Xiaorong Liu
- Department of Pediatric Nephrology, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Fang Deng
- Department of Nephrology, Anhui Provincial Children's Hospital, Hefei, China
| | - Xueqin Cheng
- Department of Nephrology, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - Li Zhang
- Department of Pediatric Nephrology, The First Hospital of Jilin University, Changchun, China
| | - Xuan Zhang
- Department of General Medicine, Tianjin Children's Hospital, Tianjin, China
| | - Huandan Yang
- Department of Nephrology, Xuzhou Children's Hospital, Xuzhou Medical University, Xuzhou, China
| | - Xiaojie Peng
- Department of Nephrology, Jiangxi Provincial Children's Hospital, Nanchang, 330006, China
| | - Qianliang Sun
- Department of Nephrology, Rheumatology and Immunology, Hunan Children's Hospital, Changsha, Hunan, China
| | - Linxia Deng
- Department of Pediatrics, Tongji Hospital, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430030, Hubei Province, China
| | - Xiaoyun Jiang
- Department of Pediatric Nephrology and Rheumatology, The First Affiliated Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Min Xie
- Department of Pediatric Nephrology, Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Chengdu, 611731, China
| | - Yan Gao
- Pediatric Nephrology Department, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, Guangzhou, 510623, Guangdong, China
| | - Lichun Yu
- Department of Pediatric Nephrology and Rheumatism and Immunology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, 250021, China
| | - Ling Liu
- Nephrology and Immunology Department, Children's Hospital of Hebei Province, Shijiazhuang, Hebei Province, China
| | - Chunlin Gao
- Department of Pediatrics, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| | - Jianhua Mao
- Department of Nephrology, Children Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Weihua Zheng
- Department of Nephrology and Rheumatology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xiqiang Dang
- Department of Pediatrics, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Hua Xia
- Department of Nephrology, Children's Hospital Affiliated to Capital Institute of Pediatrics, Beijing, China
| | - Yujie Wang
- Medical Data Science Center, Medical Research Center, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, China
| | - Xuhui Zhong
- Department of Pediatric Nephrology, Peking University First Hospital, No. 1 Xi An Men Da Jie, Beijing, 100034, People's Republic of China.
| | - Jie Ding
- Department of Pediatric Nephrology, Peking University First Hospital, No. 1 Xi An Men Da Jie, Beijing, 100034, People's Republic of China.
| | - Jicheng Lv
- Renal Division, Peking University First Hospital, No.8 Xi Shi Ku Da Jie, Beijing, 100034, People's Republic of China.
| | - Hong Zhang
- Renal Division, Peking University First Hospital, No.8 Xi Shi Ku Da Jie, Beijing, 100034, People's Republic of China
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Schaefer F, Montini G, Kang HG, Walle JV, Zaritsky J, Schreuder MF, Litwin M, Scalise A, Scott H, Potts J, Iveli P, Breitenstein S, Warady BA. Investigating the use of finerenone in children with chronic kidney disease and proteinuria: design of the FIONA and open-label extension studies. Trials 2024; 25:203. [PMID: 38509517 PMCID: PMC10956186 DOI: 10.1186/s13063-024-08021-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 02/26/2024] [Indexed: 03/22/2024] Open
Abstract
INTRODUCTION Proteinuria is a modifiable risk factor for chronic kidney disease (CKD) progression in children. Finerenone, a selective, non-steroidal, mineralocorticoid receptor antagonist (MRA) has been approved to treat adults with CKD associated with type 2 diabetes mellitus (T2DM) following results from the phase III clinical trials FIDELIO-DKD (NCT02540993) and FIGARO-DKD (NCT02545049). In a pre-specified pooled analysis of both studies (N = 13,026), finerenone was shown to have an acceptable safety profile and was efficacious in decreasing the risk of adverse kidney and cardiovascular outcomes and of proteinuria. OBJECTIVE FIONA and the associated open-label extension (OLE) study aim to demonstrate that combining finerenone with an angiotensin-converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) is safe, well-tolerated, and effective in sustainably reducing urinary protein excretion in children with CKD and proteinuria. DESIGN FIONA (NCT05196035; Eudra-CT: 2021-002071-19) is a randomized (2:1), double-blind, placebo-controlled, multicenter, phase III study of 6 months' duration in approximately 219 pediatric patients. Patients must have a clinical diagnosis of CKD (an eGFR ≥ 30 mL/min/1.73 m2 if ≥ 1 to < 18 years or a serum creatinine level ≤ 0.40 mg/dL for infants 6 months to < 1 year) with significant proteinuria despite ACEi or ARB usage. The primary objective is to demonstrate that finerenone, added to an ACEi or ARB, is superior to placebo in reducing urinary protein excretion. FIONA OLE (NCT05457283; Eudra-CT: 2021-002905-89) is a single-arm, open-label study, enrolling participants who have completed FIONA. The primary objective of FIONA OLE is to provide long-term safety data. FIONA has two primary endpoints: urinary protein-to-creatinine ratio (UPCR) reduction of ≥ 30% from baseline to day 180 and percent change in UPCR from baseline to day 180. A sample size of 198 participants (aged 2 to < 18 years) in FIONA will provide at least 80% power to reject the null hypothesis of either of the two primary endpoints. CONCLUSION FIONA is evaluating the use of finerenone in children with CKD and proteinuria. Should safety, tolerability, and efficacy be demonstrated, finerenone could become a useful additional therapeutic agent in managing proteinuria and improving kidney outcomes in children with CKD. TRIAL REGISTRATION ClinicalTrials.gov NCT05196035. Registered on 19 January 2022.
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Affiliation(s)
- Franz Schaefer
- Pediatric Nephrology Division, Heidelberg University Hospital, Heidelberg, Germany.
| | - Giovanni Montini
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Department of Pediatric Nephrology, Dialysis and Transplant Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Hee Gyung Kang
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, South Korea
| | - Johan Vande Walle
- Department of Pediatric Nephrology, Ghent University Hospital, Erknet Center, C4C, Ghent, Belgium
| | - Joshua Zaritsky
- Department of Nephrology, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Michiel F Schreuder
- Department of Pediatric Nephrology, Radboudumc Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Mieczyslaw Litwin
- Department of Nephrology and Arterial Hypertension, Children's Memorial Health Institute, Warsaw, Poland
| | | | - Helen Scott
- Bayer U.S Pharmaceuticals, Whippany, NJ, USA
| | - James Potts
- Bayer U.S Pharmaceuticals, Whippany, NJ, USA
| | | | | | - Bradley A Warady
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, MO, USA
- Children's Mercy Kansas City, Kansas City, MO, USA
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Masrouri S, Esmaeili F, Tohidi M, Azizi F, Hadaegh F. Rapid decline of kidney function increases fracture risk in the general population: Insights from TLGS. Bone 2024; 179:116974. [PMID: 37981179 DOI: 10.1016/j.bone.2023.116974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 11/06/2023] [Accepted: 11/16/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Although the association between Chronic Kidney Disease (CKD) and all-cause fractures was addressed in previous studies, the association between estimated glomerular filtration rate (eGFR) decline and fractures was poorly addressed. For the first time we examined the association between rapid kidney function decline (RKFD) and fracture incidence among Iranian general population. METHODS In a Tehranian community-based cohort, RKFD was defined as a 30 % decline in eGFR over 2-3 years. Cox proportional hazards models, adjusted for age, sex, current eGFR, diabetes mellitus, hypertension, dyslipidemia, current smoking, obesity status, waist circumference, prevalent cardiovascular diseases, aspirin, steroid use, education level, and marital status, were used to examine the association of RKFD with different fracture outcomes. RESULTS Among 5305 (3031 women) individuals aged ≥30 years, during the median follow-up of 9.62 years, 226 fracture events were observed. The multivariable hazard ratio of RKFD for any-fracture events, lower-extremity, and major osteoporotic fractures were 2.18 (95 % CI, 1.24-3.85), 2.32 (1.15-4.71), and 2.91 (1.29-6.58), respectively. These associations remained significant after accounting for the competing risk of death. The impact of RKFD on the development of incident all-cause fractures was not modified by gender [men: 2.64 (1.11-6.25) vs. women: 2.11 (1.00-4.47)] and according to current CKD status [without CKD: 2.34 (1.00-5.52) vs. with CKD: 2.59 (1.04-6.44)] (all P for interaction >0.5). CONCLUSIONS RKFD can increase the incidence of fractures among general population, the issue that was equally important among non-CKD individuals, emphasizing the need for early identification and management in those with rapidly declining eGFR.
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Affiliation(s)
- Soroush Masrouri
- Prevention of Metabolic Disorders Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farzad Esmaeili
- Prevention of Metabolic Disorders Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Maryam Tohidi
- Prevention of Metabolic Disorders Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Fereidoun Azizi
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farzad Hadaegh
- Prevention of Metabolic Disorders Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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Li Z, Liu X, Cheng Z, Chen Y, Tu W, Su J. TrialView: An AI-powered Visual Analytics System for Temporal Event Data in Clinical Trials. PROCEEDINGS OF THE ... ANNUAL HAWAII INTERNATIONAL CONFERENCE ON SYSTEM SCIENCES. ANNUAL HAWAII INTERNATIONAL CONFERENCE ON SYSTEM SCIENCES 2024; 2024:1169-1178. [PMID: 38681743 PMCID: PMC11052597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 05/01/2024]
Abstract
Randomized controlled trials (RCT) are the gold standards for evaluating the efficacy and safety of therapeutic interventions in human subjects. In addition to the pre-specified endpoints, trial participants' experience reveals the time course of the intervention. Few analytical tools exist to summarize and visualize the individual experience of trial participants. Visual analytics allows integrative examination of temporal event patterns of patient experience, thus generating insights for better care decisions. Towards this end, we introduce TrialView, an information system that combines graph artificial intelligence (AI) and visual analytics to enhance the dissemination of trial data. TrialView offers four distinct yet interconnected views: Individual, Cohort, Progression, and Statistics, enabling an interactive exploration of individual and group-level data. The TrialView system is a general-purpose analytical tool for a broad class of clinical trials. The system is powered by graph AI, knowledge-guided clustering, explanatory modeling, and graph-based agglomeration algorithms. We demonstrate the system's effectiveness in analyzing temporal event data through a case study.
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Vivarelli M, Bomback AS, Meier M, Wang Y, Webb NJ, Veldandi UK, Smith RJ, Kavanagh D. Iptacopan in Idiopathic Immune Complex-Mediated Membranoproliferative Glomerulonephritis: Protocol of the APPARENT Multicenter, Randomized Phase 3 Study. Kidney Int Rep 2024; 9:64-72. [PMID: 38312795 PMCID: PMC10831369 DOI: 10.1016/j.ekir.2023.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 10/16/2023] [Accepted: 10/23/2023] [Indexed: 02/06/2024] Open
Abstract
Introduction Immune complex-mediated membranoproliferative glomerulonephritis (IC-MPGN) is an ultra-rare, fast-progressing kidney disease that may be idiopathic (primary) or secondary to chronic infection, autoimmune disorders, or monoclonal gammopathies. Dysregulation of the alternative complement pathway is implicated in the pathophysiology of IC-MPGN; and currently, there are no approved targeted treatments. Iptacopan is an oral, highly potent proximal complement inhibitor that specifically binds to factor B and inhibits the alternative pathway (AP). Methods This randomized, double-blind, placebo-controlled phase 3 study (APPARENT; NCT05755386) will evaluate the efficacy and safety of iptacopan in patients with idiopathic (primary) IC-MPGN, enrolling up to 68 patients (minimum of 10 adolescents) aged 12 to 60 years with biopsy-confirmed IC-MPGN, proteinuria ≥1 g/g, and estimated glomerular filtration rate (eGFR) ≥30 ml/min per 1.73 m2. All patients will receive maximally tolerated angiotensin-converting enzyme inhibitor/angiotensin receptor blocker and vaccination against encapsulated bacteria. Patients with any organ transplant, progressive crescentic glomerulonephritis, or kidney biopsy with >50% interstitial fibrosis/tubular atrophy, will be excluded. Patients will be randomized 1:1 to receive either iptacopan 200 mg twice daily (bid) or placebo for 6 months, followed by open-label treatment with iptacopan 200 mg bid for all patients for 6 months. The primary objective of the study is to evaluate the efficacy of iptacopan versus placebo in proteinuria reduction measured as urine protein-to-creatinine ratio (UPCR) (24-h urine) at 6 months. Key secondary end points will assess kidney function measured by eGFR, patients who achieve a proteinuria-eGFR composite end point, and patient-reported fatigue. Conclusion This study will provide evidence toward the efficacy and safety of iptacopan in idiopathic (primary) IC-MPGN.
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Affiliation(s)
- Marina Vivarelli
- Division of Nephrology, Laboratory of Nephrology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Andrew S. Bomback
- Division of Nephrology, Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Matthias Meier
- Global Drug Development, Novartis Pharma AG, Basel, Switzerland
| | - Yaqin Wang
- Global Drug Development, Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | | | | | - Richard J.H. Smith
- Molecular Otolaryngology and Renal Research Laboratories and the Departments of Internal Medicine and Pediatrics (Divisions of Nephrology), Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - David Kavanagh
- National Renal Complement Therapeutics Centre, Newcastle upon Tyne Hospitals, National Health Service Foundation Trust, Newcastle upon Tyne, UK
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Pisani A, Pieruzzi F, Cirami CL, Riccio E, Mignani R. Interpretation of GFR slope in untreated and treated adult Fabry patients. Nephrol Dial Transplant 2023; 39:18-25. [PMID: 37442614 DOI: 10.1093/ndt/gfad164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Indexed: 07/15/2023] Open
Abstract
Nephropathy is one of the main features of Fabry disease (FD) that leads, in untreated patients with classical mutations, to end-stage renal disease (ESRD) from the third to the fifth decade of life. The availability of a specific treatment modified the natural history of FD; in particular, it was widely reported that enzyme replacement therapy (ERT) is able to slow the progression of the disease. Regarding Fabry nephropathy, several reports have documented an elevated estimated glomerular filtration rate (eGFR) slope in untreated patients as expression of a rapid disease progression towards ESRD. Otherwise, the prompt start of treatment may be beneficial in stabilizing renal function or slowing its decline. Therefore, based on data in the literature about the effects of ERT on eGFR decline and on the evidence supporting the role of eGFR slope as a surrogate endpoint for chronic kidney disease progression, we suggest, in this 'Expert Opinion', that a treatment should be defined effective when eGFR decline is <1 ml/min/1.73 m2/year and not effective when eGFR loss remains ≥3 ml/min/1.73 m2/year (≥2.5 ml/min/1.73 m2/year in females). Moreover, practical clinical recommendations and guidance for Fabry patients suggests that a change in treatment may be appropriate if individualized therapeutic goals are not achieved. Since a dose-dependent efficacy has been demonstrated for ERT, we suggest considering a switch to a higher dose of ERT in symptomatic adult Fabry patients (ages 18-60 years) with an eGFR of 45-90 ml/min/1.73 m2 and treated with a stable dose of ERT for at least 1 year, in which a linear negative slope of eGFR of 3 ml/min/1.73 m2/year for males (2.5 ml/min/1.73 m2/year for females) was observed.
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Affiliation(s)
- Antonio Pisani
- Chair of Nephrology, Department of Public Health, Federico II University of Naples, Naples, Italy
| | - Federico Pieruzzi
- Clinical Nephrology, Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | | | - Eleonora Riccio
- Chair of Nephrology, Department of Public Health, Federico II University of Naples, Naples, Italy
| | - Renzo Mignani
- Nephrology, Dialysis and Transplantation, IRCCS S. Orsola University Hospital, University of Bologna, Bologna, Italy
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Little DJ, Gasparyan SB, Schloemer P, Jongs N, Brinker M, Karpefors M, Tasto C, Rethemeier N, Frison L, Nkulikiyinka R, Rossert J, Heerspink HJ. Validity and Utility of a Hierarchical Composite End Point for Clinical Trials of Kidney Disease Progression: A Review. J Am Soc Nephrol 2023; 34:1928-1935. [PMID: 37807165 PMCID: PMC10703071 DOI: 10.1681/asn.0000000000000244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 09/21/2023] [Indexed: 10/10/2023] Open
Abstract
Clinical trials in nephrology often use composite end points comprising clinical events, such as onset of ESKD and initiation of kidney function replacement therapy, along with a sustained large ( e.g. , ≥50%) decrease in GFR. Such events typically occur late in the disease course, resulting in large trials in which most participants do not contribute clinical events. In addition, components of the end point are considered of equal importance; however, their clinical significance varies. For example, kidney function replacement therapy initiation is likely to be clinically more meaningful than GFR decline of ≥50%. By contrast, hierarchical composite end points (HCEs) combine multiple outcomes and prioritize each patient's most clinically relevant outcome for inclusion in analysis. In this review, we consider the use of HCEs in clinical trials of CKD progression, emphasizing the potential to combine dichotomous clinical events such as those typically used in CKD progression trials, with the continuous variable of GFR over time, while ranking all components according to clinical significance. We consider maraca plots to visualize overall treatment effects and the contributions of individual components, discuss the application of win odds in kidney HCE trials, and review general design considerations for clinical trials for CKD progression with kidney HCE as an efficacy end point.
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Affiliation(s)
- Dustin J. Little
- Late Stage Development, Cardiovascular, Renal and Metabolism (CVRM), Biopharmaceuticals R&D, AstraZeneca, Gaithersburg, Maryland
| | - Samvel B. Gasparyan
- Late Stage Development, Cardiovascular, Renal and Metabolism (CVRM), BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Patrick Schloemer
- Pharmaceuticals, Research and Development, Bayer AG, Berlin, Germany
| | - Niels Jongs
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Meike Brinker
- Pharmaceuticals, Research and Development, Bayer AG, Wuppertal, Germany
| | - Martin Karpefors
- Late Stage Development, Cardiovascular, Renal and Metabolism (CVRM), BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Christoph Tasto
- Pharmaceuticals, Research and Development, Bayer AG, Wuppertal, Germany
| | - Nicole Rethemeier
- Pharmaceuticals, Research and Development, Bayer AG, Wuppertal, Germany
| | - Lars Frison
- Late Stage Development, Cardiovascular, Renal and Metabolism (CVRM), BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | | | - Jerome Rossert
- Late Stage Development, Cardiovascular, Renal and Metabolism (CVRM), Biopharmaceuticals R&D, AstraZeneca, Gaithersburg, Maryland
| | - Hiddo J.L. Heerspink
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- The George Institute for Global Health, Sydney, New South Wales, Australia
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14
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Jin Q, Kuen Lam CL, Fai Wan EY. Association of eGFR slope with all-cause mortality, macrovascular and microvascular outcomes in people with type 2 diabetes and early-stage chronic kidney disease. Diabetes Res Clin Pract 2023; 205:110924. [PMID: 37778664 DOI: 10.1016/j.diabres.2023.110924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 09/12/2023] [Accepted: 09/27/2023] [Indexed: 10/03/2023]
Abstract
AIMS The association of estimated glomerular filtration rate (eGFR) slope with progression of complications in people with type 2 diabetes (T2D) and early-stage chronic kidney disease (CKD) is less clear. METHODS We identified 115,139 T2D participants without decreased eGFR (>60 mL/min/1.73 m2) between 2008 and 2015 from the electronic database of the Hong Kong Hospital Authority. eGFR slope calculated by linear-mixed effects model using 3-year eGFR measurements was categorized into quintiles. With Quintile 3 of eGFR slope as the reference group, we used Cox proportional or cause-specific models to investigate the association between eGFR slope and all-cause mortality, macrovascular and microvascular complications, as appropriate. RESULTS Over a median follow-up of 7.8 years, fastest eGFR declines (Quintile 1 with median eGFR slope: -4.32 mL/min/1.73 m2/year) were associated with increased risk of all adverse outcomes (adjusted hazard ratio [aHR] 1.36 to 2.97, all P < 0.0001), compared with less steep eGFR declines (Quintile 3: -1.08 mL/min/1.73 m2/year). Substantial eGFR increases (Quintile 5: 1.34 mL/min/1.73 m2/year) were associated with decreased risk of CKD and ≥ 40 % decline in eGFR (aHR [95 % CI] 0.65 [0.63, 0.67] and 0.85 [0.82, 0.89], respectively) and higher risk of death, CVD, DR and DN (aHR [95 % CI] 1.48 [1.40, 1.56], 1.19 [1.14, 1.25], 1.07 [1.004, 1.15] and 1.62 [1.37, 1.91], respectively). CONCLUSIONS In a cohort of T2D people without decreased eGFR, accelerated declines and increases in eGFR were associated with all-cause mortality, macrovascular and microvascular complications, supporting the potential prognostic utility of eGFR slope in T2D people with early-stage CKD.
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Affiliation(s)
- Qiao Jin
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Cindy Lo Kuen Lam
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China; Department of Family Medicine, The University of Hong Kong - Shenzhen Hospital, Shenzhen, China
| | - Eric Yuk Fai Wan
- Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China; Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China; Laboratory of Data Discovery for Health (D24H), Hong Kong, China.
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15
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Drawz PE, Lenoir KM, Rai NK, Rastogi A, Chu CD, Rahbari-Oskoui FF, Whelton PK, Thomas G, McWilliams A, Agarwal AK, Suarez MM, Dobre M, Powell J, Rocco MV, Lash JP, Oparil S, Raj DS, Dwyer JP, Rahman M, Soman S, Townsend RR, Pemu P, Horwitz E, Ix JH, Tuot DS, Ishani A, Pajewski NM. Effect of Intensive Blood Pressure Control on Kidney Outcomes: Long-Term Electronic Health Record-Based Post-Trial Follow-Up of SPRINT. Clin J Am Soc Nephrol 2023; 19:01277230-990000000-00273. [PMID: 37883184 PMCID: PMC10861101 DOI: 10.2215/cjn.0000000000000335] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 10/19/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND Intensive BP lowering in the Systolic Blood Pressure Intervention Trial (SPRINT) produced acute decreases in kidney function and higher risk for AKI. We evaluated the effect of intensive BP lowering on long-term changes in kidney function using trial and outpatient electronic health record (EHR) creatinine values. METHODS SPRINT data were linked with EHR data from 49 (of 102) study sites. The primary outcome was the total slope of decline in eGFR for the intervention phase and the post-trial slope of decline during the observation phase using trial and outpatient EHR values. Secondary outcomes included a ≥30% decline in eGFR to <60 ml/min per 1.73 m 2 and a ≥50% decline in eGFR or kidney failure among participants with baseline eGFR ≥60 and <60 ml/min per 1.73 m 2 , respectively. RESULTS EHR creatinine values were available for a median of 8.3 years for 3041 participants. The total slope of decline in eGFR during the intervention phase was -0.67 ml/min per 1.73 m 2 per year (95% confidence interval [CI], -0.79 to -0.56) in the standard treatment group and -0.96 ml/min per 1.73 m 2 per year (95% CI, -1.08 to -0.85) in the intensive treatment group ( P < 0.001). The slopes were not significantly different during the observation phase: -1.02 ml/min per 1.73 m 2 per year (95% CI, -1.24 to -0.81) in the standard group and -0.85 ml/min per 1.73 m 2 per year (95% CI, -1.07 to -0.64) in the intensive group. Among participants without CKD at baseline, intensive treatment was associated with higher risk of a ≥30% decline in eGFR during the intervention (hazard ratio, 3.27; 95% CI, 2.43 to 4.40), but not during the postintervention observation phase. In those with CKD at baseline, intensive treatment was associated with a higher hazard of eGFR decline only during the intervention phase (hazard ratio, 1.95; 95% CI, 1.03 to 3.70). CONCLUSIONS Intensive BP lowering was associated with a steeper total slope of decline in eGFR and higher risk for kidney events during the intervention phase of the trial, but not during the postintervention observation phase.
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Affiliation(s)
- Paul E. Drawz
- Division of Nephrology and Hypertension, University of Minnesota, Minneapolis, Minnesota
| | - Kristin M. Lenoir
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Nayanjot Kaur Rai
- Division of Nephrology and Hypertension, University of Minnesota, Minneapolis, Minnesota
| | - Anjay Rastogi
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - Chi D. Chu
- Department of Medicine, University of California, San Francisco, San Francisco, California
| | | | - Paul K. Whelton
- Department of Epidemiology, Tulane University School of Public Health and Tropical Medicine, New Orleans, Louisiana
| | - George Thomas
- Department of Kidney Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Andrew McWilliams
- Department of Internal Medicine, Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, North Carolina
| | - Anil K. Agarwal
- Department of Medicine, Veterans Affairs Central California Health Care System, Fresno, California
| | - Maritza Marie Suarez
- Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida
| | - Mirela Dobre
- Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - James Powell
- Division of General Internal Medicine, Brody School of Medicine, East Carolina University, Greenville, North Carolina
| | - Michael V. Rocco
- Section on Nephrology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - James P. Lash
- Division of Nephrology, University of Illinois at Chicago, Chicago, Illinois
| | - Suzanne Oparil
- Division of Cardiovascular Disease, University of Alabama-Birmingham, Birmingham, Alabama
| | - Dominic S. Raj
- Division of Kidney Diseases and Hypertension, George Washington University, Washington, DC
| | - Jamie P. Dwyer
- Division of Nephrology and Hypertension, University of Utah Health, Salt Lake City, Utah
| | - Mahboob Rahman
- Division of Nephrology and Hypertension, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Sandeep Soman
- Division of Nephrology and Hypertension, Henry Ford Hospital, Detroit, Michigan
| | - Raymond R. Townsend
- Perelman School of Medicine University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Edward Horwitz
- Division of Nephrology & Hypertension, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Joachim H. Ix
- Division of Nephrology-Hypertension, University of California San Diego, Veterans Affairs San Diego Healthcare System, San Diego, California
| | - Delphine S. Tuot
- Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Areef Ishani
- Division of Nephrology and Hypertension, University of Minnesota, Minneapolis, Minnesota
- Minneapolis VA Health Care System, Minneapolis, Minnesota
| | - Nicholas M. Pajewski
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, North Carolina
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Chan KW, Kwong ASK, Tan KCB, Lui SL, Chan GC, Ip TP, Yiu WH, Cowling BJ, Taam Wong V, Lao L, Feng Y, Lai KN, Tang SC. Add-on Rehmannia-6-Based Chinese Medicine in Type 2 Diabetes and CKD: A Multicenter Randomized Controlled Trial. Clin J Am Soc Nephrol 2023; 18:1163-1174. [PMID: 37307005 PMCID: PMC10564374 DOI: 10.2215/cjn.0000000000000199] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Accepted: 06/03/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND Diabetes is the leading cause of CKD and kidney failure. We assessed the real-world effectiveness of Rehmannia-6-based Chinese medicine treatment, the most used Chinese medicine formulation, on the change in eGFR and albuminuria in patients with diabetes and CKD with severely increased albuminuria. METHODS In this randomized, assessor-blind, standard care-controlled, parallel, multicenter trial, 148 adult patients from outpatient clinics with type 2 diabetes, an eGFR of 30-90 ml/min per 1.73 m 2 , and a urine albumin-to-creatinine ratio (UACR) of 300-5000 mg/g were randomized 1:1 to a 48-week add-on protocolized Chinese medicine treatment program (using Rehmannia-6-based formulations in the granule form taken orally) or standard care alone. Primary outcomes were the slope of change in eGFR and UACR between baseline and end point (48 weeks after randomization) in the intention-to-treat population. Secondary outcomes included safety and the change in biochemistry, biomarkers, and concomitant drug use. RESULTS The mean age, eGFR, and UACR were 65 years, 56.7 ml/min per 1.73 m 2 , and 753 mg/g, respectively. Ninety-five percent ( n =141) of end point primary outcome measures were retrievable. For eGFR, the estimated slope of change was -2.0 (95% confidence interval [CI], -0.1 to -3.9) and -4.7 (95% CI, -2.9 to -6.5) ml/min per 1.73 m 2 in participants treated with add-on Chinese medicine or standard care alone, resulting in a 2.7 ml/min per 1.73 m 2 per year (95% CI, 0.1 to 5.3; P = 0.04) less decline with Chinese medicine. For UACR, the estimated proportion in the slope of change was 0.88 (95% CI, 0.75 to 1.02) and 0.99 (95% CI, 0.85 to 1.14) in participants treated with add-on Chinese medicine or standard care alone, respectively. The intergroup proportional difference (0.89, 11% slower increment in add-on Chinese medicine, 95% CI, 0.72 to 1.10; P = 0.28) did not reach statistical significance. Eighty-five adverse events were recorded from 50 participants (add-on Chinese medicine versus control: 22 [31%] versus 28 [36%]). CONCLUSIONS Rehmannia-6-based Chinese medicine treatment stabilized eGFR on top of standard care alone after 48 weeks in patients with type 2 diabetes, stage 2-3 CKD, and severely increased albuminuria. CLINICAL TRIAL REGISTRY Semi-individualized Chinese Medicine Treatment as an Adjuvant Management for Diabetic Nephropathy (SCHEMATIC), NCT02488252 .
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Affiliation(s)
- Kam Wa Chan
- Division of Nephrology, Department of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Alfred Siu Kei Kwong
- Department of Family Medicine and Primary Healthcare, Hong Kong West Cluster, Hospital Authority, Hong Kong SAR, China
| | - Kathryn Choon Beng Tan
- Division of Endocrinology & Metabolism, Department of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Sing Leung Lui
- Department of Medicine, Tung Wah Hospital, Hong Kong SAR, China
| | - Gary C.W. Chan
- Department of Medicine, Queen Mary Hospital, Hong Kong SAR, China
| | - Tai Pang Ip
- Department of Medicine, Tung Wah Hospital, Hong Kong SAR, China
| | - Wai Han Yiu
- Division of Nephrology, Department of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Benjamin John Cowling
- Division of Epidemiology and Biostatistics, School of Public Health, The University of Hong Kong, Hong Kong SAR, China
| | - Vivian Taam Wong
- School of Chinese Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Lixing Lao
- School of Chinese Medicine, The University of Hong Kong, Hong Kong SAR, China
- Virginia University of Integrative Medicine, Fairfax, Virginia
| | - Yibin Feng
- School of Chinese Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Kar Neng Lai
- Division of Nephrology, Department of Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Sydney C.W. Tang
- Division of Nephrology, Department of Medicine, The University of Hong Kong, Hong Kong SAR, China
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Melzer Cohen C, Schechter M, Rozenberg A, Yanuv I, Sehtman-Shachar DR, Fishkin A, Rosenzweig D, Chodick G, Karasik A, Mosenzon O. Long-Term, Real-World Kidney Outcomes with SGLT2i versus DPP4i in Type 2 Diabetes without Cardiovascular or Kidney Disease. Clin J Am Soc Nephrol 2023; 18:1153-1162. [PMID: 37382938 PMCID: PMC10564349 DOI: 10.2215/cjn.0000000000000218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 06/11/2023] [Indexed: 06/30/2023]
Abstract
BACKGROUND Contemporary guidelines recommend the use of sodium-glucose cotransporter 2 inhibitors (SGLT2is) independently of glycemic control in patients with type 2 diabetes and those with kidney disease, with heart failure, or at high risk of cardiovascular disease. Using a large Israeli database, we assessed whether long-term use of SGLT2is versus dipeptidyl peptidase 4 inhibitors (DPP4is) is associated with kidney benefits in patients with type 2 diabetes overall and in those without evidence of cardiovascular or kidney disease. METHODS Patients with type 2 diabetes who initiated SGLT2is or DPP4is between 2015 and 2021 were propensity score-matched (1:1) according to 90 parameters. The kidney-specific composite outcome included confirmed ≥40% decline in eGFR or kidney failure. The kidney-or-death outcome included also all-cause mortality. Risks of outcomes were assessed using Cox proportional hazard regression models. The between-group difference in eGFR slope was also assessed. Analyses were repeated in patients' subgroup lacking evidence of cardiovascular or kidney disease. RESULTS Overall, 19,648 propensity score-matched patients were included; 10,467 (53%) did not have evidence of cardiovascular or kidney disease. Median follow-up was 38 months (interquartile range, 22-55). The composite kidney-specific outcome occurred at an event rate of 6.9 versus 9.5 events per 1000 patient-years with SGLT2i versus DPP4i. The respective event rates of the kidney-or-death outcome were 17.7 versus 22.1. Compared with DPP4is, initiation of SGLT2is was associated with a lower risk for the kidney-specific (hazard ratio [HR], 0.72; 95% confidence interval [CI], 0.61 to 0.86; P < 0.001) and kidney-or-death (HR, 0.80; 95% CI, 0.71 to 0.89; P < 0.001) outcomes. The respective HRs (95% CI) in those lacking evidence of cardiovascular or kidney disease were 0.67 (0.44 to 1.02) and 0.77 (0.61 to 0.97). Initiation of SGLT2is versus DPP4is was associated with mitigation of the eGFR slope overall and in those lacking evidence of cardiovascular or kidney disease (mean between-group differences 0.49 [95% CI, 0.35 to 0.62] and 0.48 [95% CI, 0.32 to 0.64] ml/min per 1.73 m 2 per year, respectively). CONCLUSIONS Long-term use of SGLT2is versus DPP4is in a real-world setting was associated with mitigation of eGFR loss in patients with type 2 diabetes, even in those lacking evidence of cardiovascular or kidney disease at baseline.
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Affiliation(s)
- Cheli Melzer Cohen
- Maccabi Institute for Research and Innovation, Maccabi Healthcare Services, Tel-Aviv, Israel
| | - Meir Schechter
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Aliza Rozenberg
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ilan Yanuv
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Dvora R. Sehtman-Shachar
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Alisa Fishkin
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | | | - Gabriel Chodick
- Maccabi Institute for Research and Innovation, Maccabi Healthcare Services, Tel-Aviv, Israel
- School of Public Health Sackler, Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avraham Karasik
- Maccabi Institute for Research and Innovation, Maccabi Healthcare Services, Tel-Aviv, Israel
- Tel Aviv University, Tel Aviv, Israel
| | - Ofri Mosenzon
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem, Israel
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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Aoki J, Kaya C, Khalid O, Kothari T, Silberman MA, Skordis C, Hughes J, Hussong J, Salama ME. CKD Progression Prediction in a Diverse US Population: A Machine-Learning Model. Kidney Med 2023; 5:100692. [PMID: 37637863 PMCID: PMC10457449 DOI: 10.1016/j.xkme.2023.100692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023] Open
Abstract
Rationale & Objective Chronic kidney disease (CKD) is a major cause of morbidity and mortality. To date, there are no widely used machine-learning models that can predict progressive CKD across the entire disease spectrum, including the earliest stages. The objective of this study was to use readily available demographic and laboratory data from Sonic Healthcare USA laboratories to train and test the performance of machine learning-based predictive risk models for CKD progression. Study Design Retrospective observational study. Setting & Participants The study population was composed of deidentified laboratory information services data procured from a large US outpatient laboratory network. The retrospective data set included 110,264 adult patients over a 5-year period with initial estimated glomerular filtration rate (eGFR) values between 15-89 mL/min/1.73 m2. Predictors Patient demographic and laboratory characteristics. Outcomes Accelerated (ie, >30%) eGFR decline associated with CKD progression within 5 years. Analytical Approach Machine-learning models were developed using random forest survival methods, with laboratory-based risk factors analyzed as potential predictors of significant eGFR decline. Results The 7-variable risk classifier model accurately predicted an eGFR decline of >30% within 5 years and achieved an area under the curve receiver-operator characteristic of 0.85. The most important predictor of progressive decline in kidney function was the eGFR slope. Other key contributors to the model included initial eGFR, urine albumin-creatinine ratio, serum albumin (initial and slope), age, and sex. Limitations The cohort study did not evaluate the role of clinical variables (eg, blood pressure) on the performance of the model. Conclusions Our progressive CKD classifier accurately predicts significant eGFR decline in patients with early, mid, and advanced disease using readily obtainable laboratory data. Although prospective studies are warranted, our results support the clinical utility of the model to improve timely recognition and optimal management for patients at risk for CKD progression. Plain-Language Summary Defined by a significant decrease in estimated glomerular filtration rate (eGFR), chronic kidney disease (CKD) progression is strongly associated with kidney failure. However, to date, there are no broadly used resources that can predict this clinically significant event. Using machine-learning techniques on a diverse US population, this cohort study aimed to address this deficiency and found that a 5-year risk prediction model for CKD progression was accurate. The most important predictor of progressive decline in kidney function was the eGFR slope, followed by the urine albumin-creatinine ratio and serum albumin slope. Although further study is warranted, the results showed that a machine-learning model using readily obtainable laboratory information accurately predicts CKD progression, which may inform clinical diagnosis and management for this at-risk population.
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Inker LA, Collier W, Greene T, Miao S, Chaudhari J, Appel GB, Badve SV, Caravaca-Fontán F, Del Vecchio L, Floege J, Goicoechea M, Haaland B, Herrington WG, Imai E, Jafar TH, Lewis JB, Li PKT, Maes BD, Neuen BL, Perrone RD, Remuzzi G, Schena FP, Wanner C, Wetzels JFM, Woodward M, Heerspink HJL. A meta-analysis of GFR slope as a surrogate endpoint for kidney failure. Nat Med 2023; 29:1867-1876. [PMID: 37330614 DOI: 10.1038/s41591-023-02418-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 05/24/2023] [Indexed: 06/19/2023]
Abstract
Glomerular filtration rate (GFR) decline is causally associated with kidney failure and is a candidate surrogate endpoint for clinical trials of chronic kidney disease (CKD) progression. Analyses across a diverse spectrum of interventions and populations is required for acceptance of GFR decline as an endpoint. In an analysis of individual participant data, for each of 66 studies (total of 186,312 participants), we estimated treatment effects on the total GFR slope, computed from baseline to 3 years, and chronic slope, starting at 3 months after randomization, and on the clinical endpoint (doubling of serum creatinine, GFR < 15 ml min-1 per 1.73 m2 or kidney failure with replacement therapy). We used a Bayesian mixed-effects meta-regression model to relate treatment effects on GFR slope with those on the clinical endpoint across all studies and by disease groups (diabetes, glomerular diseases, CKD or cardiovascular diseases). Treatment effects on the clinical endpoint were strongly associated with treatment effects on total slope (median coefficient of determination (R2) = 0.97 (95% Bayesian credible interval (BCI) 0.82-1.00)) and moderately associated with those on chronic slope (R2 = 0.55 (95% BCI 0.25-0.77)). There was no evidence of heterogeneity across disease. Our results support the use of total slope as a primary endpoint for clinical trials of CKD progression.
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Affiliation(s)
- Lesley A Inker
- Division of Nephrology, Tufts Medical Center, Boston, MA, USA.
| | - Willem Collier
- Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Tom Greene
- Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Shiyuan Miao
- Division of Nephrology, Tufts Medical Center, Boston, MA, USA
| | - Juhi Chaudhari
- Division of Nephrology, Tufts Medical Center, Boston, MA, USA
| | - Gerald B Appel
- Division of Nephrology, Columbia University Medical Center and the New York Presbyterian Hospital, New York, NY, USA
| | - Sunil V Badve
- George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | | | - Lucia Del Vecchio
- Department of Nephrology and Dialysis, Sant'Anna Hospital, ASST Lariana, Como, Italy
| | - Jürgen Floege
- Division of Nephrology, RWTH Aachen University, Aachen, Germany
| | - Marian Goicoechea
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Benjamin Haaland
- Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - William G Herrington
- Medical Research Council Population Health Research Unit, Clinical Trial Service Unit and Epidemiological Studies Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Enyu Imai
- Nakayamadera Imai Clinic, Takarazuka, Japan
| | - Tazeen H Jafar
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Julia B Lewis
- Division of Nephrology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Philip K T Li
- Division of Nephrology, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, China
| | - Bart D Maes
- Department of Nephrology, AZ Delta, Roeselare, Belgium
| | - Brendon L Neuen
- George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | | | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Francesco P Schena
- Renal, Dialysis and Transplant Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Christoph Wanner
- Renal Research Unit, Comprehensive Heart Failure Center, Department of Clinical Research and Epidemiology, University of Würzburg, Würzburg, Germany
| | - Jack F M Wetzels
- Department of Nephrology, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Mark Woodward
- George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
- George Institute for Global Health, School of Public Health, Imperial College London, London, UK
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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20
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Heerspink HJL, Jongs N, Neuen BL, Schloemer P, Vaduganathan M, Inker LA, Fletcher RA, Wheeler DC, Bakris G, Greene T, Chertow GM, Perkovic V. Effects of newer kidney protective agents on kidney endpoints provide implications for future clinical trials. Kidney Int 2023; 104:181-188. [PMID: 37119876 DOI: 10.1016/j.kint.2023.03.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Revised: 03/02/2023] [Accepted: 03/24/2023] [Indexed: 05/01/2023]
Abstract
Doubling of serum creatinine (equivalent to a 57% decline in the estimated glomerular filtration rate (eGFR)) is an accepted component of a composite kidney endpoint in clinical trials. Smaller declines in eGFR (40%, 50%) have been applied in several recently conducted clinical trials. Here, we assessed the effects of newer kidney protective agents on endpoints including smaller proportional declines in eGFR to compare relative event rates and the magnitude of observed treatment effects. We performed a post hoc analysis of 4401 patients in the CREDENCE, 4304 in the DAPA-CKD, 5734 in the FIDELIO-DKD, and 3668 in the SONAR trials, which assessed the effects of canagliflozin, dapagliflozin, finerenone and atrasentan in patients with chronic kidney disease. Effects of active therapies versus placebo on alternative composite kidney endpoints incorporating different eGFR decline thresholds (40%, 50%, or 57% eGFR reductions from baseline) with kidney failure or death due to kidney failure were compared. Cox-proportional hazards regression models were used to assess and compare treatment effects. During follow-up, event rates were higher for endpoints incorporating smaller versus larger eGFR decline thresholds. Compared to the treatment effects on kidney failure or death due to kidney failure, the magnitude of relative treatment effects was generally similar when considering composite endpoints incorporating smaller declines in eGFR. Hazard ratios for the four interventions ranged from 0.63 to 0.82 for the endpoint incorporating 40% eGFR decline and 0.59 to 0.76 for the endpoint incorporating 57% eGFR decline. Clinical trials incorporating a 40% eGFR decline in a composite endpoint would require approximately half the number of participants compared to a 57% eGFR decline with equivalent statistical power. Thus, in populations at high risk of CKD progression, the relative effects of newer kidney protective therapies appear generally similar across endpoints based on varying eGFR decline thresholds.
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Affiliation(s)
- Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands; The George Institute for Global Health, Sydney, Australia.
| | - Niels Jongs
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Brendon L Neuen
- The George Institute for Global Health, Sydney, Australia; Department of Renal Medicine, Royal North Shore Hospital, Sydney, Australia
| | | | | | - Lesley A Inker
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts, USA
| | | | - David C Wheeler
- Department of Renal Medicine, University College London, London, UK
| | - George Bakris
- Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Tom Greene
- Division of Biostatistics, Department of Population Health Sciences, University of Utah Health, Salt Lake City, Utah, USA
| | - Glenn M Chertow
- Department of Medicine, Epidemiology and Biostatistics, Stanford University School of Medicine, Stanford, California, USA; Department of Health Policy, Stanford University School of Medicine, Stanford, California, USA
| | - Vlado Perkovic
- Faculty of Medicine & Health, University New South Wales, Sydney, Australia
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21
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van der Hoek S, Jongs N, Oshima M, Neuen BL, Stevens J, Perkovic V, Levin A, Mahaffey KW, Pollock C, Greene T, Wheeler DC, Jardine MJ, Heerspink HJ. Glycemic Control and Effects of Canagliflozin in Reducing Albuminuria and eGFR: A Post Hoc Analysis of the CREDENCE Trial. Clin J Am Soc Nephrol 2023; 18:748-758. [PMID: 36999981 PMCID: PMC10278833 DOI: 10.2215/cjn.0000000000000161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 03/17/2023] [Indexed: 04/01/2023]
Abstract
BACKGROUND In the Canagliflozin and Renal Events in Diabetes with Established Nephropathy Clinical Evaluation (CREDENCE) trial, the sodium-glucose cotransporter-2 (SGLT2) inhibitor canagliflozin improved kidney and cardiovascular outcomes and reduced the rate of estimated glomerular filtration decline (eGFR slope) in patients with type 2 diabetes and CKD. In other clinical trials of patients with CKD or heart failure, the protective effects of SGLT2 inhibitors on eGFR slope were greater in participants with versus participants without type 2 diabetes. This post hoc analysis of the CREDENCE trial assessed whether the effects of canagliflozin on eGFR slope varied according to patient subgroups by baseline glycated hemoglobin A1c (HbA1c). METHODS CREDENCE ( ClinicalTrials.gov [ NCT02065791 ]) was a randomized controlled trial in adults with type 2 diabetes with an HbA1c of 6.5%-12.0%, an eGFR of 30-90 ml/min per 1.73 m 2 , and a urinary albumin-to-creatinine ratio of 300-5000 mg/g. Participants were randomly assigned to canagliflozin 100 mg once daily or placebo. We studied the effect of canagliflozin on eGFR slope using linear mixed-effects models. RESULTS The annual difference in total eGFR slope was 1.52 ml/min per 1.73 m 2 (95% confidence interval [CI], 1.11 to 1.93) slower in participants randomized to canagliflozin compared with placebo. The rate of eGFR decline was faster in those with poorer baseline glycemic control. The mean difference in total eGFR slope between canagliflozin and placebo was greater in participants with poorer baseline glycemic control (difference in eGFR slope of 0.39, 1.36, 2.60, 1.63 ml/min per 1.73 m 2 for HbA1c subgroups 6.5%-7.0%, 7.0%-8.0%, 8.0%-10.0%, 10.0%-12.0%, respectively; Pinteraction = 0.010). The mean difference in change from baseline in urinary albumin-to-creatinine ratio between participants randomized to canagliflozin and placebo was smaller in patients with baseline HbA1c 6.5%-7.0% (-17% [95% CI, -28 to -5]) compared with those with an HbA1c of 7.0%-12% (-32% [95% CI, -40 to -28]; Pinteraction = 0.03). CONCLUSIONS The effect of canagliflozin on eGFR slope in patients with type 2 diabetes and CKD was more pronounced in patients with higher baseline HbA1c, partly because of the more rapid decline in kidney function in these individuals. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER Evaluation of the Effects of Canagliflozin on Renal and Cardiovascular Outcomes in Participants With Diabetic Nephropathy (CREDENCE), NCT02065791.
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Affiliation(s)
- Sjoukje van der Hoek
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Niels Jongs
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Megumi Oshima
- Department of Nephrology and Laboratory Medicine, Kanazawa University, Kanazawa, Japan
- The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Brendon L. Neuen
- The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Jasper Stevens
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Vlado Perkovic
- Faculty of Medicine & Health, University New South Wales, Sydney, New South Wales, Australia
| | - Adeera Levin
- Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Carol Pollock
- Kolling Institute of Medical Research, Sydney Medical School, University of Sydney, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Tom Greene
- Division of Biostatistics, Department of Population Health Sciences, University of Utah Health, Salt Lake City, Utah
| | - David C. Wheeler
- Department of Renal Medicine, University College London, London, United Kingdom
| | - Meg J. Jardine
- NHMRC Clinical Trials Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Hiddo J.L. Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center, Groningen, The Netherlands
- The George Institute for Global Health, Sydney, New South Wales, Australia
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Butler J, Packer M, Siddiqi TJ, Böhm M, Brueckmann M, Januzzi JL, Verma S, Gergei I, Iwata T, Wanner C, Ferreira JP, Pocock SJ, Filippatos G, Anker SD, Zannad F. Efficacy of Empagliflozin in Patients With Heart Failure Across Kidney Risk Categories. J Am Coll Cardiol 2023; 81:1902-1914. [PMID: 37164523 DOI: 10.1016/j.jacc.2023.03.390] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 02/14/2023] [Accepted: 03/07/2023] [Indexed: 05/12/2023]
Abstract
BACKGROUND Empagliflozin reduces the risk of major heart failure outcomes in heart failure with reduced or preserved ejection fraction. OBJECTIVES The goal of this study was to evaluate the effect of empagliflozin across the spectrum of chronic kidney disease in a pooled analysis of EMPEROR-Reduced and EMPEROR-Preserved (Empagliflozin Outcome Trial in Patients with Chronic Heart Failure with Reduced or Preserved Ejection Fraction, respectively). METHODS A total of 9,718 patients were grouped into Kidney Disease Improving Global Outcomes (KDIGO) categories based on estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio into low-, moderate-, high-, and very-high-risk categories, comprising 32.0%, 29.1%, 21.9%, and 17.0% of the participants, respectively. RESULTS In the placebo arm, when compared with lower risk categories, patients at higher risk experienced a slower rate of decline in eGFR, but a higher risk of a composite kidney event. Empagliflozin reduced the risk of cardiovascular death or heart failure hospitalizations similarly in all KDIGO categories (HR: 0.81; 95% CI: 0.66-1.01 for low-; HR: 0.63; 95% CI: 0.52-0.76 for moderate-; HR: 0.82; 95% CI: 0.68-0.98 for high-; and HR: 0.84; 95% CI: 0.71-1.01 for very-high-risk groups; P trend = 0.30). Empagliflozin reduced the rate of decline in eGFR whether it was estimated by chronic slope, total slope, or unconfounded slope. When compared with the unconfounded slope, the magnitude of the effect on chronic slope was larger, and the effect on total slope was smaller. In EMPEROR-Reduced, patients at lowest risk experienced the largest effect of empagliflozin on eGFR slope; this pattern was not observed in EMPEROR-Preserved. CONCLUSIONS The benefit of empagliflozin on major heart failure events was not influenced by KDIGO categories. The magnitude of the renal effects of the drug depended on the approach used to calculate eGFR slopes.
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Affiliation(s)
- Javed Butler
- Baylor Scott and White Research Institute, Dallas, Texas, USA; Department of Medicine, University of Mississippi School of Medicine, Jackson, Mississippi, USA.
| | - Milton Packer
- Baylor University Medical Center, Dallas, Texas, USA; Imperial College, London, United Kingdom
| | - Tariq Jamal Siddiqi
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Michael Böhm
- Department of Internal Medicine III, University Hospital Saarland, Saarland University, Homburg, Saar, Germany
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, Ingelheim, Germany; First Department of Medicine, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - James L Januzzi
- Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Subodh Verma
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Ingrid Gergei
- Boehringer Ingelheim International GmbH, Ingelheim, Germany; Fifth Department of Medicine, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Tomoko Iwata
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | | | - João Pedro Ferreira
- Centre d'Investigations Cliniques Plurithématique 14-33, Inserm U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Université de Lorraine, Nancy, France; Cardiovascular Research and Development Center, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens School of Medicine, Athens University Hospital Attikon, Athens, Greece
| | - Stefan D Anker
- Department of Cardiology (CVK) and Berlin Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Germany, Charité Universitätsmedizin Berlin, Berlin, Germany; Institute of Heart Diseases, Wrocław Medical University, Wrocław, Poland
| | - Faiez Zannad
- Centre d'Investigations Cliniques Plurithématique 14-33, Inserm U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Université de Lorraine, Nancy, France
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Han M, Moon S, Lee S, Kim K, An WJ, Ryu H, Kang E, Ahn JH, Sung HY, Park YS, Lee SE, Lee SH, Jeong KH, Ahn C, Kelly TN, Hsu JY, Feldman HI, Park SK, Oh KH. Novel Genetic Variants Associated with Chronic Kidney Disease Progression. J Am Soc Nephrol 2023; 34:857-875. [PMID: 36720675 PMCID: PMC10125649 DOI: 10.1681/asn.0000000000000066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 12/11/2022] [Indexed: 02/02/2023] Open
Abstract
SIGNIFICANCE STATEMENT eGFR slope has been used as a surrogate outcome for progression of CKD. However, genetic markers associated with eGFR slope among patients with CKD were unknown. We aimed to identify genetic susceptibility loci associated with eGFR slope. A two-phase genome-wide association study identified single nucleotide polymorphisms (SNPs) in TPPP and FAT1-LINC02374 , and 22 of them were used to derive polygenic risk scores that mark the decline of eGFR by disrupting binding of nearby transcription factors. This work is the first to identify the impact of TPPP and FAT1-LINC02374 on CKD progression, providing predictive markers for the decline of eGFR in patients with CKD. BACKGROUND The incidence of CKD is associated with genetic factors. However, genetic markers associated with the progression of CKD have not been fully elucidated. METHODS We conducted a genome-wide association study among 1738 patients with CKD, mainly from the KoreaN cohort study for Outcomes in patients With CKD. The outcome was eGFR slope. We performed a replication study for discovered single nucleotide polymorphisms (SNPs) with P <10 -6 in 2498 patients with CKD from the Chronic Renal Insufficiency Cohort study. Several expression quantitative trait loci (eQTL) studies, pathway enrichment analyses, exploration of epigenetic architecture, and predicting disruption of transcription factor (TF) binding sites explored potential biological implications of the loci. We developed and evaluated the effect of polygenic risk scores (PRS) on incident CKD outcomes. RESULTS SNPs in two novel loci, TPPP and FAT1-LINC02374 , were replicated (rs59402340 in TPPP , Pdiscovery =7.11×10 -7 , PCRIC =8.13×10 -4 , Pmeta =7.23×10 -8 ; rs28629773 in FAT1-LINC02374 , Pdiscovery =6.08×10 -7 , PCRIC =4.33×10 -2 , Pmeta =1.87×10 -7 ). The eQTL studies revealed that the replicated SNPs regulated the expression level of nearby genes associated with kidney function. Furthermore, these SNPs were near gene enhancer regions and predicted to disrupt the binding of TFs. PRS based on the independently significant top 22 SNPs were significantly associated with CKD outcomes. CONCLUSIONS This study demonstrates that SNP markers in the TPPP and FAT1-LINC02374 loci could be predictive markers for the decline of eGFR in patients with CKD.
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Affiliation(s)
- Miyeun Han
- Department of Internal Medicine, National Medical Center, Seoul, Korea
| | - Sungji Moon
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Korea
- Cancer Research Institute, Seoul National University, Seoul, Korea
- Interdisciplinary Program in Cancer Biology, Seoul National University College of Medicine, Seoul, Korea
- Genomic Medicine Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Sangjun Lee
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Korea
- Cancer Research Institute, Seoul National University, Seoul, Korea
- Department of Biomedical Science, Seoul National University Graduate School, Seoul, Korea
| | - Kyungsik Kim
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Korea
- Cancer Research Institute, Seoul National University, Seoul, Korea
- Department of Biomedical Science, Seoul National University Graduate School, Seoul, Korea
| | - Woo Ju An
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Korea
- Cancer Research Institute, Seoul National University, Seoul, Korea
- Integrated Major in Innovative Medical Science, Seoul National University College of Medicine, Seoul, Korea
| | - Hyunjin Ryu
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Eunjeong Kang
- Department of Internal Medicine, Ewha Womans University Seoul Hospital, Ewha Womans University College of Medicine, Seoul, Korea
| | - Jung-Hyuck Ahn
- Department of Biochemistry, Ewha Womans University College of Medicine, Seoul, Korea
| | - Hye Youn Sung
- Department of Biochemistry, Ewha Womans University College of Medicine, Seoul, Korea
| | - Yong Seek Park
- Department of Microbiology, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Seung Eun Lee
- Department of Microbiology, School of Medicine, Kyung Hee University, Seoul, Korea
| | - Sang-Ho Lee
- Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, Korea
| | - Kyung Hwan Jeong
- Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, Korea
| | - Curie Ahn
- Department of Internal Medicine, National Medical Center, Seoul, Korea
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Tanika N. Kelly
- Department of Epidemiology, Tulane University, New Orleans, Louisiana
| | - Jesse Y. Hsu
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Harold I. Feldman
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Sue K. Park
- Department of Preventive Medicine, Seoul National University College of Medicine, Seoul, Korea
- Cancer Research Institute, Seoul National University, Seoul, Korea
- Integrated Major in Innovative Medical Science, Seoul National University College of Medicine, Seoul, Korea
| | - Kook-Hwan Oh
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
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Schwab S, Sidler D, Haidar F, Kuhn C, Schaub S, Koller M, Mellac K, Stürzinger U, Tischhauser B, Binet I, Golshayan D, Müller T, Elmer A, Franscini N, Krügel N, Fehr T, Immer F. Clinical prediction model for prognosis in kidney transplant recipients (KIDMO): study protocol. Diagn Progn Res 2023; 7:6. [PMID: 36879332 PMCID: PMC9990297 DOI: 10.1186/s41512-022-00139-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 12/22/2022] [Indexed: 03/08/2023] Open
Abstract
BACKGROUND Many potential prognostic factors for predicting kidney transplantation outcomes have been identified. However, in Switzerland, no widely accepted prognostic model or risk score for transplantation outcomes is being routinely used in clinical practice yet. We aim to develop three prediction models for the prognosis of graft survival, quality of life, and graft function following transplantation in Switzerland. METHODS The clinical kidney prediction models (KIDMO) are developed with data from a national multi-center cohort study (Swiss Transplant Cohort Study; STCS) and the Swiss Organ Allocation System (SOAS). The primary outcome is the kidney graft survival (with death of recipient as competing risk); the secondary outcomes are the quality of life (patient-reported health status) at 12 months and estimated glomerular filtration rate (eGFR) slope. Organ donor, transplantation, and recipient-related clinical information will be used as predictors at the time of organ allocation. We will use a Fine & Gray subdistribution model and linear mixed-effects models for the primary and the two secondary outcomes, respectively. Model optimism, calibration, discrimination, and heterogeneity between transplant centres will be assessed using bootstrapping, internal-external cross-validation, and methods from meta-analysis. DISCUSSION Thorough evaluation of the existing risk scores for the kidney graft survival or patient-reported outcomes has been lacking in the Swiss transplant setting. In order to be useful in clinical practice, a prognostic score needs to be valid, reliable, clinically relevant, and preferably integrated into the decision-making process to improve long-term patient outcomes and support informed decisions for clinicians and their patients. The state-of-the-art methodology by taking into account competing risks and variable selection using expert knowledge is applied to data from a nationwide prospective multi-center cohort study. Ideally, healthcare providers together with patients can predetermine the risk they are willing to accept from a deceased-donor kidney, with graft survival, quality of life, and graft function estimates available for their consideration. STUDY REGISTRATION Open Science Framework ID: z6mvj.
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Affiliation(s)
| | - Daniel Sidler
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Fadi Haidar
- Department of Medicine, Division of Nephrology, University Hospital of Geneva, Geneva, Switzerland
| | - Christian Kuhn
- Nephrology and Transplantation Medicine, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Stefan Schaub
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Michael Koller
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Katell Mellac
- Clinic for Transplantation Immunology and Nephrology, University Hospital Basel, Basel, Switzerland
| | - Ueli Stürzinger
- STCS Patient Advisory Board, University Hospital Basel, Basel, Switzerland
| | - Bruno Tischhauser
- STCS Patient Advisory Board, University Hospital Basel, Basel, Switzerland
| | - Isabelle Binet
- Nephrology and Transplantation Medicine, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Déla Golshayan
- Transplantation Center, Lausanne University Hospital, Lausanne, Switzerland
| | - Thomas Müller
- Department of Nephrology, University Hospital Zurich, Zurich, Switzerland
| | | | | | | | - Thomas Fehr
- Department of Internal Medicine, Cantonal Hospital Graubünden, Chur, Switzerland
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25
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Almas T, Alsufyani R, Jiffry R, Subai AKA, Almesri A, Ali SA, Baqal O, Malik J, Ahmed T, Rana MN. Estimated Glomerular Filtration Rate (eGFR) Slope Assessment as a Surrogate End-point in Cardiovascular trials: Implications, Impediments, and Future Directions. Curr Probl Cardiol 2023; 48:101508. [PMID: 36402218 DOI: 10.1016/j.cpcardiol.2022.101508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 11/11/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Talal Almas
- Royal College of Surgeons in Ireland, Dublin, Ireland.
| | | | - Riaz Jiffry
- Royal College of Surgeons in Ireland, Dublin, Ireland
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26
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Changes in urinary albumin as a surrogate for kidney disease progression in people with type 2 diabetes. Clin Exp Nephrol 2023; 27:465-472. [PMID: 36840900 DOI: 10.1007/s10157-023-02328-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 02/07/2023] [Indexed: 02/26/2023]
Abstract
BACKGROUND It remains unclear whether urinary albumin changes can predict subsequent kidney disease progression in people with diabetes. METHODS This retrospective cohort study included 4570 Japanese adults with type 2 diabetes (T2D). The exposure was changes in urinary albumin-to-creatinine ratio (UACR) over 3 years, categorized into three categories: ≤ - 30%, minor change, or ≥ 30%. During the exposure period, eGFR decline was also examined and categorized into two categories: < 30% or ≥ 30% decline. The primary outcome was the composite of eGFR halving or initiation of kidney replacement therapy (KRT). The secondary outcome was the initiation of KRT. RESULTS In the spline model, the hazard ratio for the primary outcome increased linearly on the log2 scale of UACR changes. When classified into six groups based on the categories of UACR changes and eGFR decline, people with a ≤ - 30% UACR change and < 30% eGFR decline had a 38% lower incidence of the outcome compared to those with a minor UACR change and < 30% eGFR decline. Meanwhile, the risk in those with a ≤ - 30% UACR change and ≥ 30% eGFR decline was 2.89 times. People with a ≥ 30% UACR change had the higher risk, regardless of whether a ≥ 30% eGFR decline occurred. Similar results were obtained in the secondary outcome. CONCLUSIONS UACR changes can be a useful surrogate for kidney disease progression in people with T2D. However, when setting a decrease in UACR as the surrogate, it may be necessary to simultaneously evaluate kidney function decline.
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Li X, Liang Q, Zhong J, Gan L, Zuo L. The Effect of Metabolic Syndrome and Its Individual Components on Renal Function: A Meta-Analysis. J Clin Med 2023; 12:jcm12041614. [PMID: 36836149 PMCID: PMC9962508 DOI: 10.3390/jcm12041614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 02/01/2023] [Accepted: 02/15/2023] [Indexed: 02/22/2023] Open
Abstract
BACKGROUND Observational studies have reported inconsistent findings in the relationship between metabolic syndrome (MetS), its components, and loss of renal function, mainly including eGFR decline, new-onset CKD, and ESRD. This meta-analysis was performed to investigate their potential associations. METHODS PubMed and EMBASE were systematically searched from their inception to 21 July 2022. Observational cohort studies in English assessing the risk of renal dysfunction in individuals with MetS were identified. Risk estimates and their 95% confidence intervals (CIs) were extracted and pooled using the random-effects approach. RESULTS A total of 32 studies with 413,621 participants were included in the meta-analysis. MetS contributed to higher risks of renal dysfunction (RR = 1.50, 95% CI = 1.39-1.61) and, specifically, rapid decline in eGFR (RR 1.31, 95% CI 1.13-1.51), new-onset CKD (RR 1.47, 95% CI 1.37-1.58), as well as ESRD (RR 1.55, 95% CI 1.08-2.22). Moreover, all individual components of MetS were significantly associated with renal dysfunction, while elevated BP conveyed the highest risk (RR = 1.37, 95% CI = 1.29-1.46), impaired fasting glucose with the lowest and diabetic-dependent risk (RR = 1.20, 95% CI = 1.09-1.33). CONCLUSIONS Individuals with MetS and its components are at higher risk of renal dysfunction.
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Collier W, Inker LA, Haaland B, Appel GB, Badve SV, Caravaca-Fontán F, Chalmers J, Floege J, Goicoechea M, Imai E, Jafar TH, Lewis JB, Li PK, Locatelli F, Maes BD, Neuen BL, Perrone RD, Remuzzi G, Schena FP, Wanner C, Heerspink HJ, Greene T. Evaluation of Variation in the Performance of GFR Slope as a Surrogate End Point for Kidney Failure in Clinical Trials that Differ by Severity of CKD. Clin J Am Soc Nephrol 2023; 18:183-192. [PMID: 36754007 PMCID: PMC10103374 DOI: 10.2215/cjn.0000000000000050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 12/02/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND The GFR slope has been evaluated as a surrogate end point for kidney failure in meta-analyses on a broad collection of randomized controlled trials (RCTs) in CKD. These analyses evaluate how accurately a treatment effect on GFR slope predicts a treatment effect on kidney failure. We sought to determine whether severity of CKD in the patient population modifies the performance of GFR slope. METHODS We performed Bayesian meta-regression analyses on 66 CKD RCTs to evaluate associations between effects on GFR slope (the chronic slope and the total slope over 3 years, expressed as mean differences in ml/min per 1.73 m2/yr) and those of the clinical end point (doubling of serum creatinine, GFR <15 ml/min per 1.73 m2, or kidney failure, expressed as a log-hazard ratio), where models allow interaction with variables defining disease severity. We evaluated three measures (baseline GFR in 10 ml/min per 1.73 m2, baseline urine albumin-to-creatinine ratio [UACR] per doubling in mg/g, and CKD progression rate defined as the control arm chronic slope, in ml/min per 1.73 m2/yr) and defined strong evidence for modification when 95% posterior credible intervals for interaction terms excluded zero. RESULTS There was no evidence for modification by disease severity when evaluating 3-year total slope (95% credible intervals for the interaction slope: baseline GFR [-0.05 to 0.03]; baseline UACR [-0.02 to 0.04]; CKD progression rate [-0.07 to 0.02]). There was strong evidence for modification in evaluations of chronic slope (95% credible intervals: baseline GFR [0.02 to 0.11]; baseline UACR [-0.11 to -0.02]; CKD progression rate [0.01 to 0.15]). CONCLUSIONS These analyses indicate consistency of the performance of total slope over 3 years, which provides further evidence for its validity as a surrogate end point in RCTs representing varied CKD populations.
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Affiliation(s)
- Willem Collier
- Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah
- Department of Population and Public Health Sciences, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Lesley A. Inker
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Benjamin Haaland
- Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah
| | - Gerald B. Appel
- Division of Nephrology, Columbia University Medical Center and the New York Presbyterian Hospital, New York, New York
| | - Sunil V. Badve
- Renal and Metabolic Division, the George Institute for Global Health, Newtown, New South Wales, Australia
| | | | - John Chalmers
- Renal and Metabolic Division, the George Institute for Global Health, Newtown, New South Wales, Australia
| | - Jürgen Floege
- Division of Nephrology, RWTH Aachen University, Aachen, Germany
| | - Marian Goicoechea
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Enyu Imai
- Nakayamadera Imai Clinic, Takarazuka, Japan
| | - Tazeen H. Jafar
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
| | - Julia B. Lewis
- Division of Nephrology, Vanderbilt University, Nashville, Tennessee
| | - Philip K.T. Li
- Division of Nephrology, Prince of Wales Hospital, Chinese University of Hong Kong, Shatin, Hong Kong
| | - Francesco Locatelli
- Department of Nephrology, Alessandro Manzoni Hospital (past Director), ASST Lecco, Italy
| | - Bart D. Maes
- Department of Nephrology, AZ Delta, Roeselare, Belgium
| | - Brendon L. Neuen
- Renal and Metabolic Division, the George Institute for Global Health, Newtown, New South Wales, Australia
| | | | - Giuseppe Remuzzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Francesco P. Schena
- Renal, Dialysis and Transplant Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Christoph Wanner
- Division of Nephrology, University Hospital of Würzburg, Würzburg, Germany
| | - Hiddo J.L. Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Tom Greene
- Population Health Sciences, University of Utah School of Medicine, Salt Lake City, Utah
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Mc Causland FR, Claggett BL, Vaduganathan M, Desai AS, Jhund P, de Boer RA, Docherty K, Fang J, Hernandez AF, Inzucchi SE, Kosiborod MN, Lam CSP, Martinez F, Saraiva JFK, McGrath MM, Shah SJ, Verma S, Langkilde AM, Petersson M, McMurray JJV, Solomon SD. Dapagliflozin and Kidney Outcomes in Patients With Heart Failure With Mildly Reduced or Preserved Ejection Fraction: A Prespecified Analysis of the DELIVER Randomized Clinical Trial. JAMA Cardiol 2023; 8:56-65. [PMID: 36326604 PMCID: PMC9634592 DOI: 10.1001/jamacardio.2022.4210] [Citation(s) in RCA: 26] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Accepted: 09/30/2022] [Indexed: 11/05/2022]
Abstract
Importance Sodium-glucose cotransporter 2 inhibitors are known to reduce heart failure events and slow progression of kidney disease among patients with heart failure and a reduced ejection fraction. Objective To determine the effect of dapagliflozin on cardiovascular and kidney outcomes and the influence of baseline kidney disease among patients with heart failure and a mildly reduced or preserved ejection fraction enrolled in the Dapagliflozin Evaluation to Improve the Lives of Patients With Preserved Ejection Fraction Heart Failure (DELIVER) trial. Design, Setting, and Participants This was a prespecified analysis conducted from July 1 to September 18, 2022 of the DELIVER randomized clinical trial. This was an international, multicenter trial including patients with ejection fraction greater than 40% and estimated glomerular filtration rate (eGFR) of 25 mL/min/1.73 m2 or higher. Interventions Dapagliflozin, 10 mg, per day or placebo. Main Outcomes and Measures Outcomes assessed were whether baseline kidney function modified the treatment effect on the primary outcome (cardiovascular death or worsening heart failure). Also examined was the treatment effect on the prespecified outcomes of eGFR slope and a post hoc composite kidney outcome (first ≥50% decline in eGFR from baseline; first eGFR <15 mL/min/1.73 m2; end-stage kidney disease; death from kidney causes). Results A total of 6262 patients (mean [SD] age, 72 [10] years; 3516 male [56%]) had mean (SD) eGFR measurements available: 61 (19) mL/min/1.73 m2; 3070 patients (49%) had an eGFR less than 60 mL/min/1.73 m2. The effect of dapagliflozin on the primary outcome was not influenced by baseline eGFR category (eGFR ≥60 mL/min/1.73 m2: hazard ratio [HR], 0.84; 95% CI, 0.70-1.00; eGFR 45-<60 mL/min/1.73 m2: HR, 0.68; 95% CI, 0.54-0.87; eGFR <45 mL/min/1.73 m2: HR, 0.93; 95% CI, 0.76-1.14; P for interaction = .16). Over a median (IQR) follow-up of 2.3 (1.7-2.8) years, the overall incidence rate of the kidney composite outcome was low (1.1 events per 100 patient-years) and was not affected by treatment with dapagliflozin (HR, 1.08; 95% CI, 0.79-1.49). However, dapagliflozin attenuated the decline in eGFR from baseline (difference, 0.5; 95% CI, 0.1-0.9 mL/min/1.73 m2 per year; P = .01) and from month 1 to 36 (difference, 1.4; 95% CI, 1.0-1.8) mL/min/1.73 m2 per year; P < .001). Conclusions and Relevance Results of this prespecified analysis showed that baseline kidney function did not modify the benefit of dapagliflozin in patients with heart failure and a mildly reduced or preserved ejection fraction. Dapagliflozin did not significantly reduce the frequency of the kidney composite outcome, although the overall event rate was low. However, dapagliflozin slowed the rate of decline in eGFR compared with placebo. Trial Registration ClinicalTrials.gov Identifier: NCT03619213.
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Affiliation(s)
- Finnian R. Mc Causland
- Renal Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Brian L. Claggett
- Harvard Medical School, Boston, Massachusetts
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Muthiah Vaduganathan
- Harvard Medical School, Boston, Massachusetts
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Akshay S. Desai
- Harvard Medical School, Boston, Massachusetts
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Pardeep Jhund
- British Heart Foundation Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Rudolf A. de Boer
- Department of Cardiology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Kieran Docherty
- British Heart Foundation Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - James Fang
- University of Utah School of Medicine, Salt Lake City
| | | | | | | | - Carolyn S. P. Lam
- National Heart Center Singapore and Duke–National University of Singapore, Singapore
| | | | - Jose F. Kerr Saraiva
- Cardiovascular Division, Instituto de Pesquisa Clínica de Campinas, Campinas, Brazil
| | - Martina M. McGrath
- Renal Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Sanjiv J. Shah
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Anna Maria Langkilde
- Late-Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden
| | - Magnus Petersson
- Late-Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals Research and Development, AstraZeneca, Gothenburg, Sweden
| | - John J. V. McMurray
- British Heart Foundation Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Scott D. Solomon
- Harvard Medical School, Boston, Massachusetts
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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Østergaard HB, Read SH, Sattar N, Franzén S, Halbesma N, Dorresteijn JA, Westerink J, Visseren FL, Wild SH, Eliasson B, van der Leeuw J. Development and Validation of a Lifetime Risk Model for Kidney Failure and Treatment Benefit in Type 2 Diabetes: 10-Year and Lifetime Risk Prediction Models. Clin J Am Soc Nephrol 2022; 17:1783-1791. [PMID: 36332974 PMCID: PMC9718022 DOI: 10.2215/cjn.05020422] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 10/14/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND AND OBJECTIVES Individuals with type 2 diabetes are at a higher risk of developing kidney failure. The objective of this study was to develop and validate a decision support tool for estimating 10-year and lifetime risks of kidney failure in individuals with type 2 diabetes as well as estimating individual treatment effects of preventive medication. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS The prediction algorithm was developed in 707,077 individuals with prevalent and incident type 2 diabetes from the Swedish National Diabetes Register for 2002-2019. Two Cox proportional regression functions for kidney failure (first occurrence of kidney transplantation, long-term dialysis, or persistent eGFR <15 ml/min per 1.73 m2) and all-cause mortality as respective end points were developed using routinely available predictors. These functions were combined into life tables to calculate the predicted survival without kidney failure while using all-cause mortality as the competing outcome. The model was externally validated in 256,265 individuals with incident type 2 diabetes from the Scottish Care Information Diabetes database between 2004 and 2019. RESULTS During a median follow-up of 6.8 years (interquartile range, 3.2-10.6), 8004 (1%) individuals with type 2 diabetes in the Swedish National Diabetes Register cohort developed kidney failure, and 202,078 (29%) died. The model performed well, with c statistics for kidney failure of 0.89 (95% confidence interval, 0.88 to 0.90) for internal validation and 0.74 (95% confidence interval, 0.73 to 0.76) for external validation. Calibration plots showed good agreement in observed versus predicted 10-year risk of kidney failure for both internal and external validation. CONCLUSIONS This study derived and externally validated a prediction tool for estimating 10-year and lifetime risks of kidney failure as well as life years free of kidney failure gained with preventive treatment in individuals with type 2 diabetes using easily available clinical predictors. PODCAST This article contains a podcast at https://dts.podtrac.com/redirect.mp3/www.asn-online.org/media/podcast/CJASN/2022_11_04_CJN05020422.mp3.
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Affiliation(s)
| | - Stephanie H. Read
- Scottish Diabetes Research Network Epidemiology Group, Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Stefan Franzén
- Swedish National Diabetes Register, Center of Registers in Region, Gothenburg, Sweden
- Health Metric Unit, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Nynke Halbesma
- Scottish Diabetes Research Network Epidemiology Group, Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | | | - Jan Westerink
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Frank L.J. Visseren
- Department of Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sarah H. Wild
- Scottish Diabetes Research Network Epidemiology Group, Usher Institute, University of Edinburgh, Edinburgh, United Kingdom
| | - Björn Eliasson
- Swedish National Diabetes Register, Center of Registers in Region, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Joep van der Leeuw
- Department of Nephrology and Hypertension, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Internal Medicine, Franciscus Gasthuis & Vlietland, Rotterdam, The Netherlands
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Zhou Y, Huang H, Yan X, Hapca S, Bell S, Qu F, Liu L, Chen X, Zhang S, Shi Q, Zeng X, Wang M, Li N, Du H, Meng W, Su B, Tian H, Li S. Glycated Haemoglobin A1c Variability Score Elicits Kidney Function Decline in Chinese People Living with Type 2 Diabetes. J Clin Med 2022; 11:6692. [PMID: 36431169 PMCID: PMC9692466 DOI: 10.3390/jcm11226692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 10/28/2022] [Accepted: 11/09/2022] [Indexed: 11/16/2022] Open
Abstract
Our aim was to investigate the association of glycated haemoglobin A1c (HbA1c) variability score (HVS) with estimated glomerular filtration rate (eGFR) slope in Chinese adults living with type 2 diabetes. This cohort study included adults with type 2 diabetes attending outpatient clinics between 2011 and 2019 from a large electronic medical record-based database of diabetes in China (WECODe). We estimated the individual-level visit-to-visit HbA1c variability using HVS, a proportion of changes in HbA1c of ≥0.5% (5.5 mmol/mol). We estimated the odds of people experiencing a rapid eGFR annual decline using a logistic regression and differences across HVS categories in the mean eGFR slope using a mixed-effect model. The analysis involved 2397 individuals and a median follow-up of 4.7 years. Compared with people with HVS ≤ 20%, those with HVS of 60% to 80% had 11% higher odds of experiencing rapid eGFR annual decline, with an extra eGFR decline of 0.93 mL/min/1.73 m2 per year on average; those with HVS > 80% showed 26% higher odds of experiencing a rapid eGFR annual decline, with an extra decline of 1.83 mL/min/1.73 m2 per year on average. Chinese adults with type 2 diabetes and HVS > 60% could experience a more rapid eGFR decline.
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Affiliation(s)
- Yiling Zhou
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Hongmei Huang
- Department of Endocrinology and Metabolism, The First People’s Hospital of Shuangliu District, Chengdu 610200, China
| | - Xueqin Yan
- Department of Chronic Disease Management, Pidu District Second People’s Hospital, Chengdu 610000, China
| | - Simona Hapca
- Division of Computing Science and Mathematics, University of Stirling, Stirling FK9 4LA, UK
| | - Samira Bell
- Division of Population Health Science and Genomics, School of Medicine, University of Dundee, Dundee DD2 4BF, UK
| | - Furong Qu
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu 610041, China
- Department of General Practice, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Li Liu
- Department of Endocrinology and Metabolism, Second People’s Hospital of Ya’an City, Ya’an 625000, China
| | - Xiangyang Chen
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu 610041, China
- Department of Endocrinology and Metabolism, The First People’s Hospital of Shuangliu District, Chengdu 610200, China
| | - Shengzhao Zhang
- Department of Pharmacy, Karamay Central Hospital, Karamay 834000, China
- Department of Pharmacy, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Qingyang Shi
- Chinese Evidence-Based Medicine Center, Cochrane China Center, MAGIC China Center, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Xiaoxi Zeng
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu 610041, China
- West China Biomedical Big Data Center, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Miye Wang
- Department of Informatics, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Nan Li
- Department of Informatics, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Heyue Du
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu 610041, China
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Wentong Meng
- Laboratory of Stem Cell Biology, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Baihai Su
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Haoming Tian
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu 610041, China
| | - Sheyu Li
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, Chengdu 610041, China
- Chinese Evidence-Based Medicine Center, Cochrane China Center, MAGIC China Center, West China Hospital, Sichuan University, Chengdu 610041, China
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Buvall L, Menzies RI, Williams J, Woollard KJ, Kumar C, Granqvist AB, Fritsch M, Feliers D, Reznichenko A, Gianni D, Petrovski S, Bendtsen C, Bohlooly-Y M, Haefliger C, Danielson RF, Hansen PBL. Selecting the right therapeutic target for kidney disease. Front Pharmacol 2022; 13:971065. [DOI: 10.3389/fphar.2022.971065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022] Open
Abstract
Kidney disease is a complex disease with several different etiologies and underlying associated pathophysiology. This is reflected by the lack of effective treatment therapies in chronic kidney disease (CKD) that stop disease progression. However, novel strategies, recent scientific breakthroughs, and technological advances have revealed new possibilities for finding novel disease drivers in CKD. This review describes some of the latest advances in the field and brings them together in a more holistic framework as applied to identification and validation of disease drivers in CKD. It uses high-resolution ‘patient-centric’ omics data sets, advanced in silico tools (systems biology, connectivity mapping, and machine learning) and ‘state-of-the-art‘ experimental systems (complex 3D systems in vitro, CRISPR gene editing, and various model biological systems in vivo). Application of such a framework is expected to increase the likelihood of successful identification of novel drug candidates based on strong human target validation and a better scientific understanding of underlying mechanisms.
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33
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Inker LA, Grams ME, Guðmundsdóttir H, McEwan P, Friedman R, Thompson A, Weiner DE, Willis K, Heerspink HJL. Clinical Trial Considerations in Developing Treatments for Early Stages of Common, Chronic Kidney Diseases: A Scientific Workshop Cosponsored by the National Kidney Foundation and the US Food and Drug Administration. Am J Kidney Dis 2022; 80:513-526. [PMID: 35970679 DOI: 10.1053/j.ajkd.2022.03.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 03/14/2022] [Indexed: 02/02/2023]
Abstract
In the past decade, advances in the validation of surrogate end points for chronic kidney disease (CKD) progression have heightened interest in evaluating therapies in early CKD. In December 2020, the National Kidney Foundation sponsored a scientific workshop in collaboration with the US Food and Drug Administration (FDA) to explore patient, provider, and payor perceptions of the value of treating early CKD. The workshop reviewed challenges for trials in early CKD, including trial designs, identification of high-risk populations, and cost-benefit and safety considerations. Over 90 people representing a range of stakeholders including experts in clinical trials, nephrology, cardiology and endocrinology, patient advocacy organizations, patients, payors, health economists, regulators and policy makers attended a virtual meeting. There was consensus among the attendees that there is value to preventing the development and treating the progression of early CKD in people who are at high risk for progression, and that surrogate end points should be used to establish efficacy. Attendees also concluded that cost analyses should be holistic and include aspects beyond direct savings for treatment of kidney failure; and that safety data should be collected outside/beyond the duration of a clinical trial. Successful drug development and implementation of effective therapies will require collaboration across sponsors, patients, patient advocacy organizations, medical community, regulators, and payors.
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Affiliation(s)
- Lesley A Inker
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts.
| | - Morgan E Grams
- Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | | | - Phil McEwan
- Health Economics and Outcomes Research Limited, Cardiff, United Kingdom
| | | | - Aliza Thompson
- Division of Cardiology and Nephrology, Office of New Drugs, Center for Drug Evaluation and Research, Food and Drug Administration, Silver Spring, Maryland
| | - Daniel E Weiner
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | | | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands; George Institute for Global Health, Sydney, Australia
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Khanijou V, Zafari N, Coughlan MT, MacIsaac RJ, Ekinci EI. Review of potential biomarkers of inflammation and kidney injury in diabetic kidney disease. Diabetes Metab Res Rev 2022; 38:e3556. [PMID: 35708187 PMCID: PMC9541229 DOI: 10.1002/dmrr.3556] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 02/18/2022] [Accepted: 04/02/2022] [Indexed: 11/17/2022]
Abstract
Diabetic kidney disease is expected to increase rapidly over the coming decades with rising prevalence of diabetes worldwide. Current measures of kidney function based on albuminuria and estimated glomerular filtration rate do not accurately stratify and predict individuals at risk of declining kidney function in diabetes. As a result, recent attention has turned towards identifying and assessing the utility of biomarkers in diabetic kidney disease. This review explores the current literature on biomarkers of inflammation and kidney injury focussing on studies of single or multiple biomarkers between January 2014 and February 2020. Multiple serum and urine biomarkers of inflammation and kidney injury have demonstrated significant association with the development and progression of diabetic kidney disease. Of the inflammatory biomarkers, tumour necrosis factor receptor-1 and -2 were frequently studied and appear to hold most promise as markers of diabetic kidney disease. With regards to kidney injury biomarkers, studies have largely targeted markers of tubular injury of which kidney injury molecule-1, beta-2-microglobulin and neutrophil gelatinase-associated lipocalin emerged as potential candidates. Finally, the use of a small panel of selective biomarkers appears to perform just as well as a panel of multiple biomarkers for predicting kidney function decline.
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Affiliation(s)
- Vuthi Khanijou
- Melbourne Medical SchoolUniversity of MelbourneAustin HealthMelbourneVictoriaAustralia
| | - Neda Zafari
- Department of MedicineUniversity of MelbourneAustin HealthMelbourneVictoriaAustralia
| | - Melinda T. Coughlan
- Department of DiabetesCentral Clinical SchoolMonash UniversityAlfred Medical Research AllianceMelbourneVictoriaAustralia
- Baker Heart & Diabetes InstituteMelbourneVictoriaAustralia
| | - Richard J. MacIsaac
- Department of Endocrinology & DiabetesSt. Vincent's Hospital Melbourne and University of MelbourneMelbourneVictoriaAustralia
| | - Elif I. Ekinci
- Melbourne Medical SchoolUniversity of MelbourneAustin HealthMelbourneVictoriaAustralia
- Department of EndocrinologyAustin HealthMelbourneVictoriaAustralia
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Mc Causland FR, Lefkowitz MP, Claggett B, Packer M, Senni M, Gori M, Jhund PS, McGrath MM, Rouleau JL, Shi V, Swedberg K, Vaduganathan M, Zannad F, Pfeffer MA, Zile M, McMurray JJV, Solomon SD. Angiotensin-neprilysin inhibition and renal outcomes across the spectrum of ejection fraction in heart failure. Eur J Heart Fail 2022; 24:1591-1598. [PMID: 34989105 PMCID: PMC9253196 DOI: 10.1002/ejhf.2421] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 12/01/2021] [Accepted: 01/03/2022] [Indexed: 12/11/2022] Open
Abstract
AIMS Patients with heart failure are at higher risk of progression to end-stage renal disease (ESRD), regardless of ejection fraction (EF). We assessed the renal effects of angiotensin-neprilysin inhibition in a pooled analysis of 13 195 patients with heart failure with reduced and preserved EF. METHODS AND RESULTS We combined data from PARADIGM-HF (EF ≤40%; n = 8399) and PARAGON-HF (EF ≥45%; n = 4796) in a pre-specified pooled analysis. We assessed the effect of treatment (sacubitril/valsartan vs. enalapril or valsartan) on a composite of either ≥50% reduction in estimated glomerular filtration rate (eGFR), ESRD, or death from renal causes, in addition to changes in eGFR slope. We assessed whether baseline renal function or EF modified the effect of therapy on renal outcomes. At randomization, eGFR was 68 ± 20 ml/min/1.73 m2 in PARADIGM-HF and 63 ± 19 ml/min/1.73 m2 in PARAGON-HF. The composite renal outcome occurred in 70 of 6594 patients (1.1%) in the sacubitril/valsartan group and in 123 of 6601 patients (1.9%) in the valsartan or enalapril group (hazard ratio 0.56, 95% confidence interval [CI] 0.42-0.75; p < 0.001). The mean eGFR change was -1.8 (95% CI -1.9 to -1.7) ml/min/1.73 m2 /year for the sacubitril/valsartan group, compared with -2.4 (95% CI -2.5 to -2.2) ml/min/1.73 m2 /year for the valsartan or enalapril group. The treatment effect on the composite renal endpoint was not modified by categories of baseline eGFR (p-interaction = 0.64), but was most pronounced in those with baseline EF between 30% and 60% (p-interaction = 0.001). CONCLUSIONS In patients with heart failure, sacubitril/valsartan reduced the risk of serious adverse renal outcomes and slowed decline in eGFR, compared with valsartan or enalapril, independent of baseline renal function.
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Affiliation(s)
- Finnian R. Mc Causland
- Renal Division, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | | | - Brian Claggett
- Harvard Medical School, Boston, MA, USA
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Michele Senni
- Cardiology Division, Cardiovascular Department, Azienda Ospedaliera Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Mauro Gori
- Cardiology Division, Cardiovascular Department, Azienda Ospedaliera Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Pardeep S. Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Martina M. McGrath
- Renal Division, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Jean L. Rouleau
- Institut de Cardiologie de Montréal, Université de Montréal, Montreal, Canada
| | - Victor Shi
- Novartis Pharmaceuticals, East Hanover, NJ, USA
| | - Karl Swedberg
- Department of Molecular and Clinical Medicine, University of Gothenburg, Sweden
| | - Muthiah Vaduganathan
- Harvard Medical School, Boston, MA, USA
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Faiez Zannad
- Université de Lorraine, Inserm CIC1433, CHRU de Nancy, France
| | - Marc A. Pfeffer
- Harvard Medical School, Boston, MA, USA
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Michael Zile
- Medical University of South Carolina, Charleston, South Carolina, USA
- Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, South Carolina, USA
| | - John J. V. McMurray
- Cardiology Division, Cardiovascular Department, Azienda Ospedaliera Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Scott D. Solomon
- Harvard Medical School, Boston, MA, USA
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
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Zafarnejad R, Dumbauld S, Dumbauld D, Adibuzzaman M, Griffin P, Rutsky E. Using CUSUM in real time to signal clinically relevant decreases in estimated glomerular filtration rate. BMC Nephrol 2022; 23:287. [PMID: 35982411 PMCID: PMC9389810 DOI: 10.1186/s12882-022-02910-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 08/01/2022] [Indexed: 11/16/2022] Open
Abstract
Background The electronic health record (EHR), utilized to apply statistical methodology, assists provider decision-making, including during the care of chronic kidney disease (CKD) patients. When estimated glomerular filtration (eGFR) decreases, the rate of that change adds meaning to a patient’s single eGFR and may represent severity of renal injury. Since the cumulative sum chart technique (CUSUM), often used in quality control and surveillance, continuously checks for change in a series of measurements, we selected this statistical tool to detect clinically relevant eGFR decreases and developed CUSUMGFR. Methods In a retrospective analysis we applied an age adjusted CUSUMGFR, to signal identification of eventual ESKD patients prior to diagnosis date. When the patient signaled by reaching a specified threshold value, days from CUSUM signal date to ESKD diagnosis date (earliness days) were measured, along with the corresponding eGFR measurement at the signal. Results Signaling occurred by CUSUMGFR on average 791 days (se = 12 days) prior to ESKD diagnosis date with sensitivity = 0.897, specificity = 0.877, and accuracy = .878. Mean days prior to ESKD diagnosis were significantly greater in Black patients (905 days) and patients with hypertension (852 days), diabetes (940 days), cardiovascular disease (1027 days), and hypercholesterolemia (971 days). Sensitivity and specificity did not vary by sociodemographic and clinical risk factors. Conclusions CUSUMGFR correctly identified 30.6% of CKD patients destined for ESKD when eGFR was > 60 ml/min/1.73 m2 and signaled 12.3% of patients that did not go on to ESKD (though almost all went on to later-stage CKD). If utilized in an EHR, signaling patients could focus providers’ efforts to slow or prevent progression to later stage CKD and ESKD. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-022-02910-8.
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Affiliation(s)
- Reyhaneh Zafarnejad
- Department of Industrial Engineering, Penn State University, 310 Leonhard Bldg., University Park, PA, 16803, USA
| | - Steven Dumbauld
- Regenstrief Center for Healthcare Engineering, Purdue University, West Lafayette, IN, USA
| | | | - Mohammad Adibuzzaman
- Department of Medical Informatics and Clinical Epidemiology, Oregon Health Sciences University, Portland, OR, USA
| | - Paul Griffin
- Department of Industrial Engineering, Penn State University, 310 Leonhard Bldg., University Park, PA, 16803, USA.
| | - Edwin Rutsky
- Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL, USA
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Bomback AS, Kavanagh D, Vivarelli M, Meier M, Wang Y, Webb NJ, Trapani AJ, Smith RJ. Alternative Complement Pathway Inhibition With Iptacopan for the Treatment of C3 Glomerulopathy-Study Design of the APPEAR-C3G Trial. Kidney Int Rep 2022; 7:2150-2159. [PMID: 36217526 PMCID: PMC9546729 DOI: 10.1016/j.ekir.2022.07.004] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 06/15/2022] [Accepted: 07/04/2022] [Indexed: 11/24/2022] Open
Abstract
Introduction Complement 3 glomerulopathy (C3G) is a rare kidney disease characterized by dysregulation of the alternative pathway (AP) of the complement system. About 50% of patients with C3G progress to kidney failure within 10 years of diagnosis. Currently, there are no approved therapeutic agents for C3G. Iptacopan is an oral, first-in-class, potent, and selective inhibitor of factor B, a key component of the AP. In a Phase II study, treatment with iptacopan was associated with a reduction in proteinuria and C3 deposit scores in C3G patients with native and transplanted kidneys, respectively. Methods APPEAR-C3G (NCT04817618) is a randomized, double-blind, and placebo-controlled Phase III study to evaluate the efficacy and safety of iptacopan in C3G patients, enrolling 68 adults with biopsy-confirmed C3G, reduced C3 (<77 mg/dl), proteinuria ≥1.0 g/g, and estimated glomerular filtration rate (eGFR) ≥30 ml/min per 1.73 m2. All patients will receive maximally tolerated angiotensin-converting enzyme inhibitor/angiotensin receptor blocker and vaccination against encapsulated bacteria. Patients with any organ transplantation, progressive crescentic glomerulonephritis (GN), monoclonal gammopathy of undetermined significance, or kidney biopsy with >50% interstitial fibrosis/tubular atrophy, will be excluded. Patients will be randomized 1:1 to receive either iptacopan 200 mg twice daily or placebo for 6 months, followed by open-label treatment with iptacopan 200 mg twice daily for all patients for 6 months. The primary objective is to evaluate the efficacy of iptacopan versus placebo on proteinuria reduction urine protein:creatinine ratio (UPCR) (24 h urine). Key secondary endpoints will assess kidney function measured by eGFR, histological disease total activity score, and fatigue. Conclusion This study aims to demonstrate the clinical benefits of AP inhibition with iptacopan in C3G.
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Hilbrands L, Budde K, Bellini MI, Diekmann F, Furian L, Grinyó J, Heemann U, Hesselink DA, Loupy A, Oberbauer R, Pengel L, Reinders M, Schneeberger S, Naesens M. Allograft Function as Endpoint for Clinical Trials in Kidney Transplantation. Transpl Int 2022; 35:10139. [PMID: 35669976 PMCID: PMC9163811 DOI: 10.3389/ti.2022.10139] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 01/11/2022] [Indexed: 12/14/2022]
Abstract
Clinical study endpoints that assess the efficacy of interventions in patients with chronic renal insufficiency can be adopted for use in kidney transplantation trials, given the pathophysiological similarities between both conditions. Kidney dysfunction is reflected in the glomerular filtration rate (GFR), and although a predefined (e.g., 50%) reduction in GFR was recommended as an endpoint by the European Medicines Agency (EMA) in 2016, many other endpoints are also included in clinical trials. End-stage renal disease is strongly associated with a change in estimated (e)GFR, and eGFR trajectories or slopes are increasingly used as endpoints in clinical intervention trials in chronic kidney disease (CKD). Similar approaches could be considered for clinical trials in kidney transplantation, although several factors should be taken into account. The present Consensus Report was developed from documentation produced by the European Society for Organ Transplantation (ESOT) as part of a Broad Scientific Advice request that ESOT submitted to the EMA in 2020. This paper provides a contemporary discussion of primary endpoints used in clinical trials involving CKD, including proteinuria and albuminuria, and evaluates the validity of these concepts as endpoints for clinical trials in kidney transplantation.
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Affiliation(s)
- Luuk Hilbrands
- Department of Nephrology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Klemens Budde
- Department of Nephrology and Medical Intensive Care, Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | - Fritz Diekmann
- Department of Nephrology and Kidney Transplantation, Vall d’Hebrón University Hospital, Barcelona, Spain
| | - Lucrezia Furian
- Kidney and Pancreas Transplantation Unit, University of Padua, Padua, Italy
| | - Josep Grinyó
- Department of Clinical Sciences, University of Barcelona, Barcelona, Spain
| | - Uwe Heemann
- Department of Nephrology, Technical University of Munich, Munich, Germany
| | - Dennis A. Hesselink
- Department of Internal Medicine, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Alexandre Loupy
- Paris Translational Research Center for Organ Transplantation, Hôpital Necker, Paris, France
| | - Rainer Oberbauer
- Department of Nephrology and Dialysis, Medical University of Vienna, Vienna, Austria
| | - Liset Pengel
- Centre for Evidence in Transplantation, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, United Kingdom
| | - Marlies Reinders
- Department of Internal Medicine, Erasmus MC Transplant Institute, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Stefan Schneeberger
- Department of General, Transplant and Thoracic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Maarten Naesens
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
- *Correspondence: Maarten Naesens,
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Kim HJ, Kim SS, Song SH. Glomerular filtration rate as a kidney outcome of diabetic kidney disease: a focus on new antidiabetic drugs. Korean J Intern Med 2022; 37:502-519. [PMID: 35368179 PMCID: PMC9082447 DOI: 10.3904/kjim.2021.515] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 02/17/2022] [Indexed: 11/27/2022] Open
Abstract
Diabetes has reached epidemic proportions, both in Korea and worldwide and is associated with an increased risk of chronic kidney disease and kidney failure (KF). The natural course of kidney function among people with diabetes (especially type 2 diabetes) may be complex in real-world situations. Strong evidence from observational data and clinical trials has demonstrated a consistent association between decreased estimated glomerular filtration rate (eGFR) and subsequent development of hard renal endpoints (such as KF or renal death). The disadvantage of hard renal endpoints is that they require a long follow-up duration. In addition, there are many patients with diabetes whose renal function declines without the appearance of albuminuria, measurement of the eGFR is emphasized. Many studies have used GFR-related parameters, such as its change, decline, or slope, as clinical endpoints for kidney disease progression. In this respect, understanding the trends in GFR changes could be crucial for developing clinical management strategies for the prevention of diabetic complications. This review focuses on the clinical implication of the eGFR-related parameters that have been used so far in diabetic kidney disease. We also discuss the use of recently developed new antidiabetic drugs for kidney protection, with a focus on the GFR as clinical endpoints.
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Affiliation(s)
- Hyo Jin Kim
- Division of Nephrology, Department of Internal Medicine, Pusan National University Hospital, Busan,
Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan,
Korea
| | - Sang Soo Kim
- Biomedical Research Institute, Pusan National University Hospital, Busan,
Korea
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Pusan National University Hospital, Busan,
Korea
| | - Sang Heon Song
- Division of Nephrology, Department of Internal Medicine, Pusan National University Hospital, Busan,
Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan,
Korea
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40
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Neuen BL, Jardine MJ. SGLT2 inhibitors and finerenone: one or the other or both? Nephrol Dial Transplant 2022; 37:1209-1211. [PMID: 35212745 DOI: 10.1093/ndt/gfac046] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Indexed: 12/19/2022] Open
Affiliation(s)
- Brendon L Neuen
- The George Institute for Global Health, University of New South Wales, Sydney, Australia.,Royal North Shore Hospital, Sydney, Australia
| | - Meg J Jardine
- NHMRC Clinical Trials Centre, University of Sydney, Sydney, Australia.,Concord Repatriation General Hospital, Sydney, Australia
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41
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Akihisa T, Kataoka H, Makabe S, Manabe S, Yoshida R, Ushio Y, Sato M, Tsuchiya K, Mochizuki T, Nitta K. Initial decline in eGFR to predict tolvaptan response in autosomal-dominant polycystic kidney disease. Clin Exp Nephrol 2022; 26:540-551. [PMID: 35165806 DOI: 10.1007/s10157-022-02192-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 01/29/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND Tolvaptan, a vasopressin V2 receptor antagonist, is used to treat autosomal-dominant polycystic kidney disease (ADPKD). Although tolvaptan curbs disease progression, a few reports have examined factors related to treatment response. The estimated glomerular filtration rate (eGFR) decreases soon after tolvaptan is initiated. We investigated whether initial eGFR decline affects renal prognosis of patients. METHODS This was a single-center, retrospective observational cohort study. Eighty-three patients with ADPKD who initiated tolvaptan were selected. We analyzed the relationship of the initial eGFR change with clinical parameters and analyzed the annual eGFR change in terms of renal prognostic value using univariable and multivariable linear regression analyses. RESULTS The initial eGFR change was - 4.6 ± 8.0%/month. The initial eGFR change correlated significantly with the annual eGFR change in multivariable analysis, suggesting that the larger decline in the initial eGFR change, the better the renal prognosis. Furthermore, the change in fractional excretion (FE) of free water (FEH2O) correlated positively with initial eGFR change. FEH2O and urea nitrogen FE (FEUN) increased significantly; however, sodium FE (FENa) level remained unchanged. In approximately half of the patients, FENa unexpectedly decreased. CONCLUSIONS The initial eGFR decline might be caused by suppressing glomerular hyperfiltration, due to the pharmacological effect of tolvaptan, and/or by reducing renal plasma flow, due to potential volume depletion. The initial eGFR change reflects the tolvaptan effect, can be easily evaluated in clinical practice, and may be useful as one of the clinical indicator for predicting renal prognosis in patients under tolvaptan.
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Affiliation(s)
- Taro Akihisa
- Department of Nephrology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Hiroshi Kataoka
- Department of Nephrology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Shiho Makabe
- Department of Nephrology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Shun Manabe
- Department of Nephrology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Rie Yoshida
- Department of Nephrology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Yusuke Ushio
- Department of Nephrology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Masayo Sato
- Department of Nephrology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Ken Tsuchiya
- Department of Blood Purification, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Toshio Mochizuki
- Department of Nephrology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan.
| | - Kosaku Nitta
- Department of Nephrology, Tokyo Women's Medical University, 8-1 Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
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Cristoferi I, Giacon TA, Boer K, van Baardwijk M, Neri F, Campisi M, Kimenai HJAN, Clahsen-van Groningen MC, Pavanello S, Furian L, Minnee RC. The applications of DNA methylation as a biomarker in kidney transplantation: a systematic review. Clin Epigenetics 2022; 14:20. [PMID: 35130936 PMCID: PMC8822833 DOI: 10.1186/s13148-022-01241-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Accepted: 01/27/2022] [Indexed: 12/27/2022] Open
Abstract
Background Although kidney transplantation improves patient survival and quality of life, long-term results are hampered by both immune- and non-immune-mediated complications. Current biomarkers of post-transplant complications, such as allograft rejection, chronic renal allograft dysfunction, and cutaneous squamous cell carcinoma, have a suboptimal predictive value. DNA methylation is an epigenetic modification that directly affects gene expression and plays an important role in processes such as ischemia/reperfusion injury, fibrosis, and alloreactive immune response. Novel techniques can quickly assess the DNA methylation status of multiple loci in different cell types, allowing a deep and interesting study of cells’ activity and function. Therefore, DNA methylation has the potential to become an important biomarker for prediction and monitoring in kidney transplantation.
Purpose of the study The aim of this study was to evaluate the role of DNA methylation as a potential biomarker of graft survival and complications development in kidney transplantation. Material and Methods A systematic review of several databases has been conducted. The Newcastle–Ottawa scale and the Jadad scale have been used to assess the risk of bias for observational and randomized studies, respectively.
Results Twenty articles reporting on DNA methylation as a biomarker for kidney transplantation were included, all using DNA methylation for prediction and monitoring. DNA methylation pattern alterations in cells isolated from different tissues, such as kidney biopsies, urine, and blood, have been associated with ischemia–reperfusion injury and chronic renal allograft dysfunction. These alterations occurred in different and specific loci. DNA methylation status has also proved to be important for immune response modulation, having a crucial role in regulatory T cell definition and activity. Research also focused on a better understanding of the role of this epigenetic modification assessment for regulatory T cells isolation and expansion for future tolerance induction-oriented therapies. Conclusions Studies included in this review are heterogeneous in study design, biological samples, and outcome. More coordinated investigations are needed to affirm DNA methylation as a clinically relevant biomarker important for prevention, monitoring, and intervention. Supplementary Information The online version contains supplementary material available at 10.1186/s13148-022-01241-7.
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Affiliation(s)
- Iacopo Cristoferi
- Division of HPB and Transplant Surgery, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015GD, Rotterdam, the Netherlands. .,Department of Pathology and Clinical Bioinformatics, Erasmus MC, University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015GD, Rotterdam, the Netherlands. .,Erasmus MC Transplant Institute, Erasmus MC, University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015GD, Rotterdam, the Netherlands.
| | - Tommaso Antonio Giacon
- Kidney and Pancreas Transplantation Unit, Department of Surgical, Oncological and Gastroenterological Sciences, Padua University Hospital, Via Giustiniani 2, 35128, Padua, Italy.,Occupational Medicine, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padua University, Via Giustiniani 2, 35128, Padua, Italy.,Environmental and Respiratory Physiology Laboratory, Department of Biomedical Sciences, Padua University, Via Marzolo 3, 35131, Padua, Italy.,Institute of Anaesthesia and Intensive Care, Department of Medicine - DIMED, Padua University Hospital, Via Cesare Battisti 267, 35128, Padua, Italy
| | - Karin Boer
- Erasmus MC Transplant Institute, Erasmus MC, University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015GD, Rotterdam, the Netherlands.,Division of Nephrology and Transplantation, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015GD, Rotterdam, The Netherlands
| | - Myrthe van Baardwijk
- Division of HPB and Transplant Surgery, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015GD, Rotterdam, the Netherlands.,Department of Pathology and Clinical Bioinformatics, Erasmus MC, University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015GD, Rotterdam, the Netherlands.,Erasmus MC Transplant Institute, Erasmus MC, University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015GD, Rotterdam, the Netherlands
| | - Flavia Neri
- Kidney and Pancreas Transplantation Unit, Department of Surgical, Oncological and Gastroenterological Sciences, Padua University Hospital, Via Giustiniani 2, 35128, Padua, Italy
| | - Manuela Campisi
- Occupational Medicine, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padua University, Via Giustiniani 2, 35128, Padua, Italy
| | - Hendrikus J A N Kimenai
- Division of HPB and Transplant Surgery, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015GD, Rotterdam, the Netherlands.,Erasmus MC Transplant Institute, Erasmus MC, University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015GD, Rotterdam, the Netherlands
| | - Marian C Clahsen-van Groningen
- Department of Pathology and Clinical Bioinformatics, Erasmus MC, University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015GD, Rotterdam, the Netherlands.,Erasmus MC Transplant Institute, Erasmus MC, University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015GD, Rotterdam, the Netherlands.,Institute of Experimental Medicine and Systems Biology, RWTH Aachen University, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Sofia Pavanello
- Occupational Medicine, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padua University, Via Giustiniani 2, 35128, Padua, Italy
| | - Lucrezia Furian
- Kidney and Pancreas Transplantation Unit, Department of Surgical, Oncological and Gastroenterological Sciences, Padua University Hospital, Via Giustiniani 2, 35128, Padua, Italy
| | - Robert C Minnee
- Division of HPB and Transplant Surgery, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015GD, Rotterdam, the Netherlands.,Erasmus MC Transplant Institute, Erasmus MC, University Medical Center Rotterdam, Doctor Molewaterplein 40, 3015GD, Rotterdam, the Netherlands
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43
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Neuen BL, Tighiouart H, Heerspink HJ, Vonesh EF, Chaudhari J, Miao S, Chan TM, Fervenza FC, Floege J, Goicoechea M, Herrington WG, Imai E, Jafar TH, Lewis JB, Li PKT, Locatelli F, Maes BD, Perrone RD, Praga M, Perna A, Schena FP, Wanner C, Wetzels JF, Woodward M, Xie D, Greene T, Inker LA. Acute Treatment Effects on GFR in Randomized Clinical Trials of Kidney Disease Progression. J Am Soc Nephrol 2022; 33:291-303. [PMID: 34862238 PMCID: PMC8819983 DOI: 10.1681/asn.2021070948] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 10/28/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Acute changes in GFR can occur after initiation of interventions targeting progression of CKD. These acute changes complicate the interpretation of long-term treatment effects. METHODS To assess the magnitude and consistency of acute effects in randomized clinical trials and explore factors that might affect them, we performed a meta-analysis of 53 randomized clinical trials for CKD progression, enrolling 56,413 participants with at least one estimated GFR measurement by 6 months after randomization. We defined acute treatment effects as the mean difference in GFR slope from baseline to 3 months between randomized groups. We performed univariable and multivariable metaregression to assess the effect of intervention type, disease state, baseline GFR, and albuminuria on the magnitude of acute effects. RESULTS The mean acute effect across all studies was -0.21 ml/min per 1.73 m2 (95% confidence interval, -0.63 to 0.22) over 3 months, with substantial heterogeneity across interventions (95% coverage interval across studies, -2.50 to +2.08 ml/min per 1.73 m2). We observed negative average acute effects in renin angiotensin system blockade, BP lowering, and sodium-glucose cotransporter 2 inhibitor trials, and positive acute effects in trials of immunosuppressive agents. Larger negative acute effects were observed in trials with a higher mean baseline GFR. CONCLUSION The magnitude and consistency of acute GFR effects vary across different interventions, and are larger at higher baseline GFR. Understanding the nature and magnitude of acute effects can help inform the optimal design of randomized clinical trials evaluating disease progression in CKD.
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Affiliation(s)
- Brendon L. Neuen
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Hocine Tighiouart
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Massachusetts
- Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts
| | - Hiddo J.L. Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, Groningen, Netherlands
| | - Edward F. Vonesh
- Department of Preventive Medicine, Northwestern University, Chicago, Illinois
| | - Juhi Chaudhari
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Shiyuan Miao
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
| | - Tak Mao Chan
- Department of Medicine, University of Hong Kong, Pokfulam, Hong Kong
| | - Fernando C. Fervenza
- Division of Nephrology and Hypertension and Department of Medicine, Mayo Clinic Rochester, Minnesota
| | - Jürgen Floege
- Division of Nephrology, RWTH Aachen University, Aachen, Germany
| | - Marian Goicoechea
- Department of Nephrology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - William G. Herrington
- Medical Research Council Population Health Research Unit at the University of Oxford Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
| | - Enyu Imai
- Nakayamadera Imai Clinic, Takarazuka, Japan
| | - Tazeen H. Jafar
- Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore, Singapore
- Duke Global Health Institute, Duke University, Durham, North Carolina
| | - Julia B. Lewis
- Division of Nephrology, Vanderbilt University, Nashville, Tennessee
| | - Philip Kam-Tao Li
- Division of Nephrology, Prince of Wales Hospital, Chinese University of Hong Kong, Shatin, Hong Kong
| | | | - Bart D. Maes
- Department of Nephrology, AZ Delta, Roeselare, Belgium
| | | | - Manuel Praga
- Nephrology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Annalisa Perna
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Bergamo, Italy
| | - Francesco P. Schena
- Renal, Dialysis and Transplant Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Christoph Wanner
- Division of Nephrology, University Hospital of Würzburg, Würzburg, Germany
| | - Jack F.M. Wetzels
- Department of Nephrology, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Mark Woodward
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- The George Institute for Global Health, Imperial College London, United Kingdom
| | - Di Xie
- Division of Nephrology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Tom Greene
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Lesley A. Inker
- Division of Nephrology, Tufts Medical Center, Boston, Massachusetts
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Inker LA, Heerspink HJL, Vonesh EF, Greene T. Letter by Inker et al Regarding Article, "Pitfalls in Using Estimated Glomerular Filtration Rate Slope as a Surrogate for the Effect of Drugs on the Risk of Serious Adverse Renal Outcomes in Clinical Trials of Patients With Heart Failure". Circ Heart Fail 2022; 15:e008983. [PMID: 35014564 DOI: 10.1161/circheartfailure.121.008983] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Lesley A Inker
- Division of Nephrology, Tufts Medical Center, Boston, MA (L.A.I.)
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, the Netherlands (H.J.L.H.)
| | - Edward F Vonesh
- Department of Preventive Medicine, Division of Biostatistics, Northwestern University, Chicago, IL (E.F.V.)
| | - Tom Greene
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City (T.G.)
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45
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Khan MS, Bakris GL, Shahid I, Weir MR, Butler J. Potential Role and Limitations of Estimated Glomerular Filtration Rate Slope Assessment in Cardiovascular Trials: A Review. JAMA Cardiol 2022; 7:549-555. [PMID: 34985495 DOI: 10.1001/jamacardio.2021.5151] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Importance Cardiovascular trials have traditionally been underpowered to assess advanced chronic kidney disease (CKD) outcomes, and when included as a secondary end point, trials have used progression of CKD as incidence of some variation of a composite of end-stage kidney disease (ESKD) outcomes. Such outcomes are infrequent or occur late in cardiovascular outcome trials, which highlights the need for alternate markers for assessing the impact of interventions on kidney function at an earlier stage of the disease and, from the prevention perspective, more relevant stage of the disease. Observations Estimated glomerular filtration rate (eGFR) slope has demonstrated strong association with subsequent progression to ESKD. With adequate sample size, treatment effects in the range of 0.5 to 1.00 mL/min/1.73 m2/y had 96% probability of predicting CKD progression, defined as doubling of serum creatinine, eGFR less than 15 mL/min/1.73 m2, or ESKD. eGFR slope can be used in patients with higher baseline values and may provide CKD progression insights when few hard kidney events are observed, especially in trials with limited follow-up. However, among trials that have determined eGFR slope, significant variations exist regarding inclusion of baseline values, calculation of eGFR values, and the follow-up period, which make it difficult to compare and gauge the incremental benefit of the interventions. There are multiple challenges in computing eGFR slope in cardiovascular trials, such as accounting for initial eGFR dip, nonlinearity, and heteroscedasticity. Conclusions and Relevance eGFR slope may serve as a valuable marker to determine progression of CKD in cardiovascular trials. Further work is required to standardize data collection, follow-up duration, time points for kidney function assessment, and analytic methods to compute eGFR slope in cardiovascular trials.
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Affiliation(s)
| | - George L Bakris
- Department of Medicine, University of Chicago Medical Center, Chicago
| | - Izza Shahid
- Department of Medicine, Ziauddin University, Karachi, Pakistan
| | - Matthew R Weir
- Division of Nephrology, University of Maryland School of Medicine, Baltimore
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson
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Garcia Sanchez JJ, Thompson J, Scott DA, Evans R, Rao N, Sörstadius E, James G, Nolan S, Wittbrodt ET, Abdul Sultan A, Stefansson BV, Jackson D, Abrams KR. Treatments for Chronic Kidney Disease: A Systematic Literature Review of Randomized Controlled Trials. Adv Ther 2022; 39:193-220. [PMID: 34881414 PMCID: PMC8799552 DOI: 10.1007/s12325-021-02006-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 11/26/2021] [Indexed: 01/06/2023]
Abstract
Delaying disease progression and reducing the risk of mortality are key goals in the treatment of chronic kidney disease (CKD). New drug classes to augment renin-angiotensin-aldosterone system (RAAS) inhibitors as the standard of care have scarcely met their primary endpoints until recently. This systematic literature review explored treatments evaluated in patients with CKD since 1990 to understand what contemporary data add to the treatment landscape. Eighty-nine clinical trials were identified that had enrolled patients with estimated glomerular filtration rate 13.9-102.8 mL/min/1.73 m2 and urinary albumin-to-creatinine ratio (UACR) 29.9-2911.0 mg/g, with (75.5%) and without (20.6%) type 2 diabetes (T2D). Clinically objective outcomes of kidney failure and all-cause mortality (ACM) were reported in 32 and 64 trials, respectively. Significant reductions (P < 0.05) in the risk of kidney failure were observed in seven trials: five small trials published before 2008 had evaluated the RAAS inhibitors losartan, benazepril, or ramipril in patients with (n = 751) or without (n = 84-436) T2D; two larger trials (n = 2152-2202) published onwards of 2019 had evaluated the sodium-glucose co-transporter 2 (SGLT2) inhibitors canagliflozin (in patients with T2D and UACR > 300-5000 mg/g) and dapagliflozin (in patients with or without T2D and UACR 200-5000 mg/g) added to a background of RAAS inhibition. Significant reductions in ACM were observed with dapagliflozin in the DAPA-CKD trial. Contemporary data therefore suggest that augmenting RAAS inhibitors with new drug classes has the potential to improve clinical outcomes in a broad range of patients with CKD.
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Affiliation(s)
| | | | | | | | - Naveen Rao
- BioPharmaceuticals Medical, AstraZeneca, Academy House, 136 Hills Road, Cambridge, CB2 8PA, UK
| | | | - Glen James
- BioPharmaceuticals Medical, AstraZeneca, Academy House, 136 Hills Road, Cambridge, CB2 8PA, UK
| | - Stephen Nolan
- BioPharmaceuticals Medical, AstraZeneca, Academy House, 136 Hills Road, Cambridge, CB2 8PA, UK
| | | | - Alyshah Abdul Sultan
- BioPharmaceuticals Medical, AstraZeneca, Academy House, 136 Hills Road, Cambridge, CB2 8PA, UK
| | | | - Dan Jackson
- BioPharmaceuticals Medical, AstraZeneca, Academy House, 136 Hills Road, Cambridge, CB2 8PA, UK
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Schena FP, Tripepi G, Rossini M, Abbrescia DI, Manno C. Randomized clinical study to evaluate the effect of personalized therapy on patients with immunoglobulin a nephropathy. Clin Kidney J 2021; 15:895-902. [PMID: 35498888 PMCID: PMC9050523 DOI: 10.1093/ckj/sfab263] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Indexed: 11/17/2022] Open
Abstract
Background Randomized controlled trials (RCTs) have been conducted, stratifying idiopathic
immunoglobulin A nephropathy (IgAN) patients based on the laboratory findings [serum
creatinine, estimated glomerular filtration rate (eGFR) and daily proteinuria]. In
contrast, data from kidney biopsy have been used only for clinical diagnosis. Therefore,
IgAN patients with active or chronic renal lesions have been receiving the same therapy
in experimental and control arms of randomized clinical trials (RCTs). Methods Our clinical study of IgAN (CLIgAN) is a multicentre, prospective, controlled and
open-label RCT based on patients’ stratification at the time of their kidney biopsy. We
will consider, first, the type of renal lesions, followed by serum creatinine values,
eGFR and proteinuria. Primary and secondary endpoints will be monitored. Then, we will
determine whether personalized therapy can slow the decline of renal function and delay
end-stage kidney disease. Results We will enrol 132 IgAN patients with active renal lesions (66 patients per arm) in the
first RCT (ACIgAN). They will receive corticosteroids combined with renin–angiotensin
system blockers (RASBs) or only RASBs. A total of 294 IgAN patients with chronic or
moderate renal lesions at high or very high risk of chronic kidney disease (147 patients
per arm) will be enrolled in the second RCT (CHRONIgAN), in which they will receive
dapagliflozin, a sodium–glucose cotransporter 2 inhibitor, combined with RASBs, or RASBs
alone. Conclusion Using this approach, we hypothesize that patients could receive personalized therapy
based on renal lesions to ensure that the right drug gets to the right patient at the
right time.
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Affiliation(s)
- Francesco P Schena
- Dept Emergency and Organ Transplant, University of Bari, Bari, Italy
- Fondazione Schena, Policlinic, Bari, Italy
| | - Giovanni Tripepi
- CNR-IFC, Institute of Clinical Physiology, Reggio Calabria, Italy
| | | | | | - Carlo Manno
- Dept Emergency and Organ Transplant, University of Bari, Bari, Italy
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Heerspink HJL, Jongs N, Chertow GM, Langkilde AM, McMurray JJV, Correa-Rotter R, Rossing P, Sjöström CD, Stefansson BV, Toto RD, Wheeler DC, Greene T. Effect of dapagliflozin on the rate of decline in kidney function in patients with chronic kidney disease with and without type 2 diabetes: a prespecified analysis from the DAPA-CKD trial. Lancet Diabetes Endocrinol 2021; 9:743-754. [PMID: 34619108 DOI: 10.1016/s2213-8587(21)00242-4] [Citation(s) in RCA: 74] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 08/09/2021] [Accepted: 08/12/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Dapagliflozin reduced the risk of kidney failure in patients with chronic kidney disease with and without type 2 diabetes in the DAPA-CKD trial. In this pre-specified analysis, we assessed the effect of dapagliflozin on the rate of change in estimated glomerular filtration rate (eGFR)-ie, the eGFR slope. METHODS DAPA-CKD was a randomised controlled trial that enrolled participants aged 18 years or older, with or without type 2 diabetes, with a urinary albumin-to-creatinine ratio (UACR) of 200-5000 mg/g, and an eGFR of 25-75 mL/min per 1·73m2. Participants were randomly assigned (1:1) to oral dapagliflozin 10 mg once daily or placebo, added to standard care. In this pre-specified analysis, we analysed eGFR slope using mixed-effect models with different slopes from baseline to week 2 (acute eGFR decline), week 2 to end of treatment (chronic eGFR slope), and baseline to end of treatment (total eGFR slope). DAPA-CKD is registered with ClinicalTrials.gov, NCT03036150, and is now complete. FINDINGS Between Feb 2, 2017, and April 3, 2020, 4304 participants were recruited, of whom 2152 (50%) were assigned to dapagliflozin and 2152 (50%) were assigned to placebo. At baseline, the mean age was 62 years (SD 12), 1425 (33·1%) participants were women, 2906 (67·5%) participants had type 2 diabetes. The median on-treatment follow-up was 2·3 years (IQR 1·8-2·6). From baseline to the end of treatment, dapagliflozin compared with placebo slowed eGFR decline by 0·95 mL/min per 1·73 m2 per year (95% CI 0·63 to 1·27) in the overall cohort. Between baseline and week 2, dapagliflozin compared with placebo resulted in an acute eGFR decline of 2·61 mL/min per 1·73 m2 (2·16 to 3·06) in patients with type 2 diabetes and 2·01 mL/min per 1·73 m2 (1·36 to 2·66) in those without type 2 diabetes. Between week 2 and end of treatment, dapagliflozin compared with placebo reduced the mean rate of eGFR decline by a greater amount in patients with type 2 diabetes (mean difference in chronic eGFR slope 2·26 mL/min per 1·73 m2 per year [1·88 to 2·64]) than in those without type 2 diabetes (1·29 mL/min per 1·73 m2 per year [0·73 to 1·85]; pinteraction=0·0049). Between baseline and end of treatment, the effect of dapagliflozin compared with placebo on the decline of total eGFR slope in patients with type 2 diabetes was 1·18 mL/min per 1·73 m2 per year (0·79 to 1·56) and without type 2 diabetes was 0·46 mL/min per 1·73 m2 per year (-0·10 to 1·03; pinteraction=0·040). The total eGFR slope was steeper in patients with higher baseline HbA1c and UACR; the effect of dapagliflozin on eGFR slope was also more pronounced in patients with higher baseline HbA1c and UACR. INTERPRETATION Dapagliflozin significantly slowed long-term eGFR decline in patients with chronic kidney disease compared with placebo. The mean difference in eGFR slope between patients treated with dapagliflozin versus placebo was greater in patients with type 2 diabetes, higher HbA1c, and higher UACR. FUNDING AstraZeneca.
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Affiliation(s)
- Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands; The George Institute for Global Health, Sydney, NSW, Australia.
| | - Niels Jongs
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Glenn M Chertow
- Departments of Medicine and Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Anna Maria Langkilde
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - John J V McMurray
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Ricardo Correa-Rotter
- The National Medical Science and Nutrition Institute Salvador Zubiran, Mexico City, Mexico
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Gentofte, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - C David Sjöström
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Bergur V Stefansson
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Robert D Toto
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX, USA
| | - David C Wheeler
- The George Institute for Global Health, Sydney, NSW, Australia; Department of Renal Medicine, University College London, London, UK
| | - Tom Greene
- Study Design and Biostatistics Center, University of Utah Health Sciences, Salt Lake City, UT, USA
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Rovin BH, Adler SG, Barratt J, Bridoux F, Burdge KA, Chan TM, Cook HT, Fervenza FC, Gibson KL, Glassock RJ, Jayne DR, Jha V, Liew A, Liu ZH, Mejía-Vilet JM, Nester CM, Radhakrishnan J, Rave EM, Reich HN, Ronco P, Sanders JSF, Sethi S, Suzuki Y, Tang SC, Tesar V, Vivarelli M, Wetzels JF, Floege J. KDIGO 2021 Clinical Practice Guideline for the Management of Glomerular Diseases. Kidney Int 2021; 100:S1-S276. [PMID: 34556256 DOI: 10.1016/j.kint.2021.05.021] [Citation(s) in RCA: 661] [Impact Index Per Article: 220.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 05/25/2021] [Indexed: 12/13/2022]
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Cherney DZI, Cosentino F, Dagogo-Jack S, McGuire DK, Pratley R, Frederich R, Maldonado M, Liu CC, Liu J, Pong A, Cannon CP. Ertugliflozin and Slope of Chronic eGFR: Prespecified Analyses from the Randomized VERTIS CV Trial. Clin J Am Soc Nephrol 2021; 16:1345-1354. [PMID: 34497110 PMCID: PMC8729577 DOI: 10.2215/cjn.01130121] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 05/27/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND OBJECTIVES A reduction in the rate of eGFR decline, with preservation of ≥0.75 ml/min per 1.73 m2 per year, has been proposed as a surrogate for kidney disease progression. We report results from prespecified analyses assessing effects of ertugliflozin versus placebo on eGFR slope from the eValuation of ERTugliflozin effIcacy and Safety CardioVascular outcomes (VERTIS CV) trial (NCT01986881). DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS Patients with type 2 diabetes mellitus and established atherosclerotic cardiovascular disease were randomized to placebo, ertugliflozin 5 mg, and ertugliflozin 15 mg (1:1:1). The analyses compared the effect of ertugliflozin (pooled doses, n=5499) versus placebo (n=2747) on eGFR slope per week and per year by random coefficient models. Study periods (weeks 0-6 and weeks 6-52) and total and chronic slopes (week 0 or week 6 to weeks 104, 156, 208, and 260) were modeled separately and by baseline kidney status. RESULTS In the overall population, for weeks 0-6, the least squares mean eGFR slopes (ml/min per 1.73 m2 per week [95% confidence interval (95% CI)]) were -0.07 (-0.16 to 0.03) and -0.54 (-0.61 to -0.48) for the placebo and ertugliflozin groups, respectively; the difference was -0.47 (-0.59 to -0.36). During weeks 6-52, least squares mean eGFR slopes (ml/min per 1.73 m2 per year [95% CI]) were -0.12 (-0.70 to 0.46) and 1.62 (1.21 to 2.02) for the placebo and ertugliflozin groups, respectively; the difference was 1.74 (1.03 to 2.45). For weeks 6-156, least squares mean eGFR slopes (ml/min per 1.73 m2 per year [95% CI]) were -1.51 (-1.70 to -1.32) and -0.32 (-0.45 to -0.19) for the placebo and ertugliflozin groups, respectively; the difference was 1.19 (0.95 to 1.42). During weeks 0-156, the placebo-adjusted difference in least squares mean slope was 1.06 (0.85 to 1.27). These findings were consistent by baseline kidney status. CONCLUSIONS Ertugliflozin has a favorable placebo-adjusted eGFR slope >0.75 ml/min per 1.73 m2 per year, documenting the kidney function preservation underlying the clinical benefits of ertugliflozin on kidney disease progression in patients with type 2 diabetes mellitus and atherosclerotic cardiovascular disease. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER US National Library of Medicine, ClinicalTrials.gov NCT01986881. Date of trial registration: November 13, 2013.
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Affiliation(s)
- David Z I Cherney
- University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Francesco Cosentino
- Unit of Cardiology, Karolinska Institute & Karolinska University Hospital, Stockholm, Sweden
| | - Samuel Dagogo-Jack
- Division of Endocrinology, Diabetes, and Metabolism, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Darren K McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center and Parkland Health and Hospital System, Dallas, Texas
| | - Richard Pratley
- AdventHealth Translational Research Institute, Orlando, Florida
| | | | | | | | - Jie Liu
- Merck & Co., Inc., Kenilworth, New Jersey
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